COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX64152197 
HU261  .Am323       What  we  know  about  c 


AMERICAN  SOCIETY  FOR  THE  CONTROL  OF  CANCER,   N  Y 


WHr.T  Yffi   KNGY  ABOUT  CAWCER. 


HCMi 


A>*M2> 


Columbia  Stotoergftp 

inHeCttpofltogork 

College  of  3$f)p&itwn&  ano  gmrgeong 
Htbrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/whatweknowaboutcOOamer 


J — ^ 

What  We  Know  About  Cancer 

A  Handbook  for  the  Medical  Profession 


Prepared  by  a  Committee  of  the 
American  Society  for  the  Control  of  Cancer 

and   Published  Jointly  by  the 

American  Society  for  the  Control  of  Cancer 

and  the 

Council  on  Health  and  Public  Instruction  of  the 
American  Medical  Association 


FROM  THE 

STATE   INSTITUTE   FOR   THE   STUDY   OF 

MALIGNANT  DISEASE 

BUFFALO,  N.  Y. 


What  We  Know  About  Cancer 

A  Handbook  for  the  Medical  Profession 


Prepared  by  a  Committee  of  the 
American  Society  for  the  Control  of  Cancer 

and  Published  Jointly  by  the 

American  Society  for  the  Control  of  Cancer 

and  the 

Council    on    Health    and    Public    Instruction    of    the 

American  Medical  Association 


American  Medical  Association 

Five   Hundred  and   Thirty-Five   North    Dearborn    Street 

CHICAGO 


Am  3  23 


CONTENTS 


Foreword 5 

I.     General  Considerations 7 

Publicity  and  Education 7 

Responsibility   of   Physicians 8 

Statistics 8 

Experimental  Work   9 

Improved  Operative  Technique 10 

Radium.     Roentgen  Rays.     Cautery 11 

Serum  Treatment   13 

"Cancer  Cures"  13 

II.     Early  Diagnosis  and  Treatment 14 

Exploratory  Operation    15 

Biopsy   15 

Early  Operation  Offers  the  Best  Prospect 

of  Cure 16 

Conditions  Essential  to  Early  Operation .  .  16 

The  Patient   16 

The  Physician   17 

Examination 17 

Diagnosis    18 

'  Consent  of  Patient  to  Operation 18 

III.     "Precancerous  Conditions"   20 

(   1)   Moles    20 

(  2)   Keratoses   21 

(3)   Fissures  and  Chronic  Ulcers 21 

(  4)   Gallstones : 21 

(5)   Gastric  Ulcer 21 

(  6)   Lacerations  of  the  Cervix 21 

(  7)   Cystitis   22 

(  8)   Leukoplakia  22 

(  9)   Kraurosis  Vulvae 22 

(10)  Involution  of  Breast  and  Prostate.  .  22 

(11)  Benign  Tumors 22 

IV.     Carcinoma  of  Different  Organs 24 

(   1)   External  Skin  24 

(  2)  Lip 25 


4 

PAGE 

(3)   Tongue,  Mouth,  Jaws 26 

(  4)   Larynx   28 

(   5)   Thyroid 29 

(  6)   Esophagus    29 

(  7)   Stomach   30 

(  8)   Colon 31 

(  9)   Pancreas,  Gallbladder,  Liver 32 

( 10)  Rectum 33 

(11)  Bladder,  Prostate  34 

( 12)  Uterus  :  Cervix,  Body 35 

(13)  Ovary  37 

(14)  Breast  38 

(15)  Penis 40 

(16)  Vulva    40 

V.     Sarcoma   42 

(   1)   Bones    42 

(  2)   Fasciae   43 

(  3)   Skin— Soft  Parts 43 

(  4)   Lymphosarcoma    44 

(5)   Melanosarcoma    .  .  » 45 

VI.     Other  Malignant  Tumors 47 

(   1)   Myeloma    47 

(  2)   Endothelioma 47 

(  3)   Glioma    48 

(  4)   Hypernephroma    49 

(   5 )   Neurocytoma 49 

(  6)   Adamantinoma    50 

(  7)   Chorio-epithelioma   50 

(  8)  Teratomata  and  Mixed  Tumors...  51 

VII.     Treatment  of  Inoperable  or  Recurrent 

Cancer 53 


FOREWORD 


In  February,  1917,  by  vote  of  the  National  Council 
of  the  American  Society  for  the  Control  of  Cancer,  a 
committee  was  appointed  to  prepare  the  manuscript  of 
a  Handbook  on  Cancer  for  circulation  among  the 
members  of  the  medical  profession  of  the  United 
States.  This  was  done  as  a  part  of  the  campaign  the 
Society  inaugurated  for  the  collection  and  dissemina- 
tion of  facts  in  regard  to  cancer,  to  the  end  that  its 
mortality  might  be  reduced  by  a  wider  knowledge  of 
the  disease.  The  first  manuscript  was  submitted  to  the 
Council  of  the  Society  at  a  meeting  in  April,  1917.  The 
manuscript  was  then  sent  to  a  number  of  different 
members  of  the  Council  for  the  critical  review  of 
special  sections  of  the  pamphlet.  The  criticisms  and 
suggestions  thus  obtained  were  utilized  in  a  subsequent 
revision  of  the  manuscript,  which  was  submitted  to  the 
Council  at  a  meeting  held  on  Oct.  26,  1918,  and  with 
certain  changes,  accepted  and  ordered  published  with 
the  endorsement  of  the  Council  and  in  the  name  of  the 
Society. 

The  Handbook  is  designed  to  provide  in  a  brief  and 
readily  accessible  form  the  important  facts  about  can- 
cer in  general,  and  its  manifestations  in  the  different 
situations  where  it  most  commonly  occurs.  The  critical 
and  controversial  review  of  published  statistics  as  to 
the  end-results  of  operative  treatment  could  not  be 
included  without  enlarging  greatly  the  size  and  scope 
of  the  publication.  It  was  decided,  therefore,  to  pre- 
sent only  in  general  terms  the  expectation  of  success 
attending  the  radical  operative  treatment  of  cancer  in 
each  of  its  different  situations.  It  is  believed  that  in 
these  statements,  as  in  other  respects,  a  conservative 
view  has  been  taken  of  the  situation,  and  that  the  state- 
ments made  can  be  thoroughly  substantiated  by  the 
published  experience  of  the  foremost  surgeons  of  the 
country. 

Robert  B.  Greenough,  M.D., 

Chairman,  Boston,  Mass. 

James  Ewing,  M.D., 

New  York,  N.  Y. 

Jonathan  M.  Wainwright,  M.D., 
Scranton,  Pa. 
Committee  on  Publication  of  Handbook  on  Cancer. 
Oct.  24,  1918. 


I 

GENERAL    CONSIDERATIONS 


PUBLICITY     AND     EDUCATION 

As  a  result  of  the  campaign  which  has  been  con- 
ducted by  the  American  Society  for  the  Control  of 
Cancer  for  the  education  and  enlightenment  of  the 
lay  public  on  the  subject  of  cancer,  a  greater  and  more 
accurate  knowledge  of  this  disease  is  already  evident, 
and  many  fallacious  ideas  have  been  corrected.  This 
has  been  the  primary  and  most  necessary  step  in  the 
campaign  to  reduce  the  very  great,  and  often  unneces- 
sary, mortality  of  this  disease,  for  until  the  patient  of 
his  own  accord  seeks  medical  advice  no  steps  can,  of 
course,  be  taken  toward  making  a  diagnosis  or  apply- 
ing the  proper  treatment.  Much  yet  remains,  to  be 
done  in  the  way  of  education  of  the  public,  not  only 
in  the  more  remote  rural  districts  but  in  the  towns 
and  cities  as  well,  and  it  must  be  done  wisely  and  tem- 
perately, and  without  producing  so  great  a  fear  of  the 
disease  as  to  alarm  people  unnecessarily.  It  is  the 
knowledge  that  the  disease  can  be  cured  by  radical 
treatment  in  its  earliest  stages  that  must  be  dissem- 
inated. Many  laymen,  and  some  physicians,  find  it 
hard  to  believe  this  fact.  Cancer  is  not  a  disease  that 
runs  its  course,  like  pneumonia  or  typhoid ;  it  is  an 
actual  entity — as  much  a  part  of  the  individual  as  his 
finger  or  his  nose,  and  it  is  either  still  a  part  of  him 
and  growing  to  a  fatal  termination  or  it  must  be 
removed  entirely  in  order  that  he  may  be  cured.  The 
layman  knows  of  the  many  cases  that  are  not  cured, 
whether  an  attempt  at  cure  by  operation  has  been  made 
or  not,  but  he  rarely  knows  of  the  cured  cases,  for  the 
reason  that  the  individual  who  has  been  relieved  of  the 
disease  by  operation  goes  about  his  or  her  business  as 
well  as  ever,  and  disguises,  so  far  as  possible,  the  loss 
of  the  organ  or  the  scar  of  the  operation  by  which  life 
has  been  saved.  It  is  difficult  to  controvert  this  per- 
sonal experience  of  the  individual  by  assertions  of  the 
possibilities  or  probabilities  of  cure  by  operation,  but 
it  must  be  done  if  the  public  is  to  understand  the  actual 
facts  of  the  cancer  problem.     Every  physician  should 


8 

feel  it  his  duty  to  make  these  facts  clear  to  the  laymen 
within  his  reach.  The  physician  of  the  present  day 
must  do  far  more  than  care  for  the  cases  of  disease 
that  call  for  his  help.  He  is  the  health  officer  of  his 
own  clientele,  and  they  look  to  him  for  knowledge  to 
protect  them  from  disease.  The  instruction  which  has 
been  given  to  the  public  is  already  bearing  fruit,  and 
from  many  communities  comes  the  report  that  patients 
now  present  themselves  to  their  physicians  much 
earlier  than  in  the  past  with  symptoms  that  they  con- 
sider suggestive  of  cancer.  Under  these  circumstances 
it  behooves  us  to  consider,  as  members  'of  the  medical 
profession,  the  obligations  which  rest  upon  us  as  the 
nearest  and  the  first  sought  source  of  scientific  knowl- 
edge, to  give  to  our  patients  that  wise  counsel  which 
they  have  a  right  to  expect. 

RESPONSIBILITY     OF     PHYSICIANS 

It  is  a  well  known  fact  that  a  considerable  proportion 
of  malignant  tumors  are  not  recognized  by  the  doctor 
when  the  patient  presents  the  indefinite  early  symptoms 
of  the  disease.  Optimism  too  often  replaces  a  careful 
physical  examination.  The  great  majority  of  cancers 
of  the  rectum  are  today  treated  as  hemorrhoids  for 
from  one  to  six  months.  Uterine  discharges  are  often 
not  properly  investigated,  and  curettings  are  not  exam- 
ined. Cancer  of  the  tongue  and  mouth  is  permitted  to 
advance  because  there  is  a  positive  Wassermann. 
Metastases  are  produced  by  repeated  rough  examina- 
tions. Malignant  moles  and  epitheliomas  of  the  skin 
are  imperfectly  removed.  Clearly  inoperable  cases  are 
operated  on,  thus  bringing  operation  into  disrepute. 

These  conditions  call  for  a  far  keener  appreciation 
of  responsibility  for  the  mortality  from  cancer  than 
now  generally  exists  in  the  medical  profession.  To 
collect  and  to  make  accessible  to  the  physicians  of  this 
country  the  most  fundamental  and  essential  facts  about 
cancer  of  the  different  organs  and  regions  of  the  body 
is  the  object  of  this  pamphlet. 

STATISTICS 

Complete  returns  of  cancer  mortality  are  available 
only  for  the  registration  area  of  the  United  States, 
which,  however,  includes  approximately  70  per  cent, 
of  the  total  population.    On  the  basis  of  this  informa- 


tion  it  is  conservatively  estimated  that  the  mortality 
from  cancer  in  the  entire  continental  United  States  at 
the  present  time  (1918)  is  approximately  90,000  per 
annum.  According  to  sex,  the  mortality, by  principal 
organs  or  parts  affected,  based  on  the  figures  for  1914, 
is  as  follows : 

ESTIMATED   ANNUAL    MORTALITY    FROM    CANCER 

CONTINENTAL    UNITED    STATES, 

1914-1915 

Organs  or  Parts  Males  Females  Total 

Buccal  cavity 2,725  •       570  3,295 

Stomach  and  liver 15,787  15,056  30,843 

Peritoneum,  intestines,  rectum 4,544  6,027  10,571 

Female  generative  organs 11,965  11,965 

Female  breast 7,771  7,771 

Skin 1,982  1,098  3,080 

Others 7,838  4,637  12,475 

All  forms 32,876  47,124  80,000 

The  recorded  mortality  from  cancer  in  this,  as  in 
other  countries  of  the  world,  is  gradually  on  the 
increase.  The  annual  increase  in  the  cancer  death  rate 
is  approximately  2%  per  cent.  The  recorded  cancer 
death  rate  has  practically  doubled  during  the  last  forty 
years. 

EXPERIMENTAL     WORK 

During  the  past  ten  years  commissions  and  labora- 
tories for  cancer  investigation  have  been  established 
in  many  places  in  the  United  States,  as  well  as  abroad. 
In  all  of  these  centers  research  work  has  been  carried 
on  on  the  tumors  of  animals  as  well  as  on  human  can- 
cer. All  of  the  resources  of  chemistry,  physics,  physi- 
ology and  biology,  and  the  study  of  immunity  reactions 
have  been  brought  to  bear  upon  the  problem,  and  the 
work  is  still  being  carried  on ;  but,  as  yet,  the  ultimate 
cause  of  cancer  is  not  known.  Many  important  facts, 
however,  have  been  discovered,  and  by  every  fact 
contributed  the  growing  structure  of  our  knowledge 
of  the  disease  is  built  up  until,  for  instance,  we  now 
know  many  things  that  cancer  is  not,  and  useless 
expenditure  in  investigation  along  those  lines  has 
ceased.  We  know  that  cancer  is  not  due,  in  the  sense 
that  infectious  diseases  are  due,  to  a  parasite.  We 
know  that  cancer  is  not  communicated  from  one  person 
to  another,  and  that  there  is  no  danger  of  the  nurse 
contracting  the  disease  in  caring  for  the  cancer  patient. 
We  know  that  the  influence  of  heredity  in  the  incidence 


10 

of  the  common  forms  of  cancer  in  human  beings  is  so 
remote  that  the  factor  of  inheritance  may,  as  a  rule, 
be  disregarded.  We  know  that  one  form  of  cancel 
after  another  has  been  brought  in  relation  to  some 
form  of  chronic  irritation,  as  a  direct  or  indirect  pre- 
disposing influence,  and  that  cancer  of  the  cervix,  the 
lip,  the  tongue,  the  rectum,  the  stomach,  and  many  of 
the  forms  of  malignant  disease  of  the  external  skin — 
Marjolin's  ulcer,  the  Kangri  cancer  of  Kashmir,  the 
paraffin  worker's  cancer,  and  the  roentgen-ray  worker's 
cancer — are  all  closely  associated  in  their  inception 
with  one  form  or  another  of  chronic  and  repeated  irri- 
tation. It  has  also  been  shown  in  the  laboratory  that 
rough  compression  and  manipulation  of  a  tumor  are 
fully  capable  of  setting  its  cells  free  to  form  metastases, 
and  from  this  we  learn  to  use  the  utmost  gentleness  in 
the  palpation  of  a  tumor  for  diagnosis,  as  well  as  to 
avoid  compression,  dragging,  and  all  unnecessary 
trauma  to  cancer  tissue  during  the  operation  for  its 
removal.  All  of  these  facts  we  owe  to  the  laboratory 
investigation  of  cancer,  and  we  may  reasonably  hope 
that  the  next  decade  will  contribute  as  much,  or  more 
information  concerning  this  disease. 

IMPROVED     OPERATIVE     TECHNIC 

In  the  great  surgical  clinics  the  technical  details  of 
the  operative  treatment  of  cancer  of  the  different 
organs  are  constantly  under  investigation  with  a  view 
to  improvement  and  to  greater  effectiveness.  For  most 
of  the  common  sites  of  cancer  the  operative  technic 
of  the  so-called  radical  operation  is  practically  stand- 
ardized. The  site  of  origin  and  the  mode  of  dissem- 
ination of  cancer  in  the  different  organs  is  well  known, 
and  each  standard  operation  aims  to  remove  the  tissues 
of  origin  and  the  tissues  suspected  of  secondary 
involvement,  by  a  wide  margin  and  without  cutting 
into  cancer  tissue  or  scattering  it  broadcast  in  the 
wound.  There  are  problems  still  to  be  solved  along 
these  lines,  especially  in  the  simplification  of  the  oper- 
ation and  in  the  reduction  of  the  mortality  and  the 
possible  complications,  as  in  cancer  of  the  tongue  or 
cancer  of  the  uterus.  It  is  possible,  however,  to  give 
a  fair  and  guarded  estimate  of  the  comparative  mor- 
tality, and  of  the  prospect  of  success  of  the  operative 


11 

treatment  of  cancer  in  different  organs.  A  successful 
radical  operation  results  in  the  cure  of  cancer.  While 
it  is  everywhere  admitted  that  no  fixed  limit  of  time 
exists  at  the  expiration  of  which  an  individual  patient 
may  be  said  with  certainty  to  be  "cured"  of  the  dis- 
ease, yet  it  is  a  fact  that  the  ordinary  three-year  period 
is  sufficient  for  all  practical  purposes.  While 
undoubtedly  late  recurrence  may  take  place  after  the 
three-year  period  has  elapsed  in  a  small  number  of 
cases,  especially  in  certain  forms  of  cancer  such  as 
cancer  of  the  breast  and  cancer  of  the  stomach,  in  the 
vast  majority  of  cases  recurrence  comes  within  this 
period,  if  at  all ;  and  the  radical  operation  may  be  con- 
sidered practically,  if  not  absolutely,  certain  of  success 
if  no  signs  of  disease  have  developed  within  three 
years. 

RADIUM,     ROENTGEN     RAY     AND     CAUTERY 

Radium  and  Roentgen  Ray. — The  effects  of  roent- 
gen rays  and  of  the  radiation  of  radium,  and  of  other 
radioactive  substances  on  cancer  tissue,  have  aroused 
great  interest  and  much  experimental  and  clinical  study 
of  their  action  has  been  made.  In  general,  it  may  be 
said  that  effects  ranging  all  the  way  from  retardation 
of  growth  to  actual  destruction  of  tumor  tissue  can  be 
secured  by  radiation.  Certain  forms  of  cancer  tissue 
appear  to  show  a  greater  susceptibility  to  the  action 
of  these  radiations  than  the  normal  tissues  of  the  body ; 
especially  is  this  true  in  regard  to  lymphoma,  lympho- 
sarcoma, giant-cell  sarcoma  of  bone,  and  mixed  tumors 
of  the  salivary  glands.  Cancer  of  the  mucous  mem- 
branes which  is  accessible  to  the  direct  application  of 
radium  radiation  can  often  be  destroyed  by  treatment. 
When  metastatic  deposits  of  cancer  are  present  in  the 
lymph  nodes,  however,  by  extension  from  the  point  of 
origin  in  the  mucous  membranes,  radium  cannot  be 
counted  on  to  destroy  the  disease,  and  a  permanent 
cure  is  not  to  be  expected.  For  these  reasons  radium 
is  a  safe  method  of  treatment  only  for  superficial  can- 
cer of  the  skin  of  the  nonmetastasizing  types,  or  for 
other  forms  of  surface  cancer  which  have  been  in 
existence  so  short  a  time  that  metastasis  to  the  regional 
lymph  nodes  cannot  possibly  have  already  taken  place. 
This  period  is  at  best  an  indefinite  one;  but  we  do 


12 

know  that  in  certain  locations,  such  as  the  tongue  or 
lip,  eariy  metastasis  is  the  rule,  while  in  other  situa- 
tions this  period  may  be  more  prolonged.  It  is  for 
these  reasons  that  the  proper  treatment  of  established 
cancer  of  the  lip,  tongue,  breast  and  other  organs 
which  are  prone  to  cancer  of  the  early  metastasizing 
type  is  considered  by  surgeons  to  be  by  radical  opera- 
tion, with  removal  of  the  regional  lymph  nodes.  The 
use  of  radium  for  treatment  of  local  lesions  of  this 
nature,  unless  accompanied  by  surgical  removal  of  the 
suspected  lymph  nodes,  is  inadequate,  and  is  not  justi- 
fied by  our  present  knowledge  of  the  effects  of  radium 
on  cancer  tissue.  For  superficial  nonmetastasizing 
cancer,  however,  and  for  many  superficial  skin  lesions, 
such  as  keratosis  senilis,  or  papillomata,  which  have 
a  precancerous  tendency,  treatment  by  radium  is  to  be 
preferred  to  operation.  In  certain  cases  of  extensive 
nonmetastasizing  cancer,  also,  the  combination  of  oper- 
ative treatment  and  subsequent  radiation  is  a  recog- 
nized and  valuable  procedure,  and  in  the  treatment  of 
inoperable  and  incurable  cancer  roentgen  rays  and 
radium  offer  a  field  of  the  greatest  usefulness.  Under 
heavy  radiation  a  bleeding,  ulcerated,  offensive  surface 
can  often  be  cleaned  up  rapidly,  even  though  the  dis- 
ease continues  to  infiltrate  the  tissues  and  the  meta- 
static deposits  increase  until  the  patient  dies.  There  is 
no  question  of  the  symptomatic  relief  and  comfort 
afforded  to  the  patient  by  palliative  treatment  with 
roentgen  rays  and  radium. 

Cautery. — A  method  of  treatment  of  cancer  which 
has  a  certain  number  of  advocates  is  that  of  cauteriza- 
tion. For  small,  superficial  lesions  the  actual  cautery 
has  long  been  employed,  with  some  success.  When 
the  disease  is  entirely  destroyed  the  method  is  satis- 
factory, although  the  healing  of  the  wound  is  pro- 
longed and  painful,  and  the  scars  produced  are  far 
more  unsightly  than  after  operation.  A  special  adapta- 
tion of  the  cautery  to  uterine  carcinoma  has  been  advo- 
cated in  the  use  of  low  heat  and  prolonged  treatment. 
This  method  is  still  under  trial,  and  it  would  be  prema- 
ture at  this  time  to  pass  on  its  merits.  Other  fields, 
however,  are  open  to  the  use  of  the  cautery  in  many 
forms  of  cancer:  First,  its  use  is  strongly  urged  by  a 
certain    number    of    surgeons    as    the    most    effective 


13 

method  to  seal  the  lymphatics  immediately  after  exci- 
sion of  a  portion  of  a  tumor  for  frozen  section  diag- 
nosis, and,  second,  the  cautery  may  be  employed  for 
the  palliative  treatment  of  inoperable,  ulcerated  and 
bleeding  tumors,  often  in  association  with  radium  or 
the  roentgen  rays.  For  the  primary  radical  treatment 
of  operable  cases  of  carcinoma  of  the  deeper  tissues, 
however,  the  use  of  the  cautery  must  be  condemned. 

SERUM     TREATMENT 

There  have  been  innumerable  attempts  to  produce 
a  cure  for  cancer  by  drugs  or  tissue  products,  instead 
of  by  the  mechanical  destruction  or  removal  of  the 
tissue  which  is  obtained  by  radioactive  agents,  cauter- 
ization or  surgical  operation.  Not  one  of  these  meth- 
ods has  withstood  the  critical  test  of  time — the  serum 
of  supposedly  resistant  or  cured  human  cases ;  the 
serum  of  animals  subjected  to  inoculations  of  human 
cancer  tissue;  the  injection  of  human  cancer  emulsions 
as  a  vaccine,  or  of  bacterial  toxins.  Each  method  has 
been  given  fair  scientific  trial  and  has  been  found  to 
be  of  insufficient  value  to  warrant  its  continued  use. 

"cancer    cures" 

Drugs  of  all  kinds  have  been  employed,  both  for 
local  administration  by  injection  or  as  caustic  pastes, 
and  for  more  general  constitutional  effect.  In  some 
the  active  agent  is  known  as  creosote ;  in  others  the 
remedy  is  secret,  and  the  compound  is  sold  at  a  high 
price  to  physicians  or  to  laymen  who  are  sufficiently 
credulous  to  purchase.  No  series  of  authentic  cures  of 
cancer  has  yet  been  demonstrated  by  any  of  these 
methods.  Finally,  the  fake  "cancer  cures,"  herb  and 
Indian  doctors,  and  Christian  scientists,  increase  enor- 
mously the  mortality  from  cancer.  It  is  charitable  to 
suppose  that  they  do  this  rather  from  ignorance  than 
by  intention,  but  the  result  is  the  same  in  any  case. 
The  patient  is  encouraged  to  expect  relief,  until  his 
money  is  exhausted  and  his  disease  is  too  far  advanced 
for  cure  by  operation,  when  he  finally  drifts  to  the 
charity  hospitals,  where  his  sufferings  can  be  con- 
trolled only  by  opiates,  and  he  dies  a  lingering  death, 
offensive  as  well  to  himself  as  to  all  with  whom  he 
comes  in  contact. 


II 

EARLY    DIAGNOSIS    AND 
TREATMENT 


The  early  diagnosis  of  cancer  is  recognized  to  be  the 
one  factor  of  the  greatest  importance  in  the  successful 
control  of  the  disease,  and  it  is  well  for  us  to  consider 
all  of  the  conditions  on  which  this  early  diagnosis 
depends.  Unfortunately,  cancer  in  the  different  organs 
and  regions  of  the  body  presents  itself  by  a  variety 
of  different  symptoms  such  that  they  must  be  consid- 
ered not  as  manifestations  of  one  disease,  but  rather 
as  of  many  different  diseases.  In  most  situations, 
however,  the  dictum  holds  true  that  the  more  certain 
the  diagnosis-  the  less  the  probability  of  cure.  In  one 
organ,  as  the  breast  for  instance,  the  earliest  symptom 
of  cancer  may  be  either  a  tumor,  discovered  by  acci- 
dent, or  an  indrawing  of  the  nipple  or  puckering  of 
the  skin.  In  another,  as  the  tongue,  the  first  symptom 
noted  by  the  patient  is  an  ulceration  which  shows  no 
tendency  to  heal.  In  other  portions  of  the  body,  like 
the  uterus  or  the  rectum,  the  first  symptom  to  attract 
the  notice  of  the  patient,  or  the  physician,  may  be  a 
discharge  of  blood  from  an  internal  ulcerated  surface, 
which  is  only  to  be  detected  by  a  digital  or  visual  exam- 
ination. In  all  of  these  situations  conditions  other  than 
cancer  may  give  rise  to  similar  symptoms — in  other 
words,  the  symptoms  of  early  cancer  are  not  distinctive 
and  serve  only  to  arouse  suspicion  of  the  presence  of 
that  disease.  When  the  abdominal  viscera  are  affected 
by  cancer  the  symptoms  are  still  less  definite,  and  the 
early  diagnosis  is  made  even  more  difficult.  In  these 
regions,  however,  the  development  of  examination  by 
the  roentgen  ray  has  given  us  a  means  of  early  diag- 
nosis which  is  not  to  be  neglected.  When  symptoms 
are  present,  suggestive  of  cancer  but  insufficient  to 
make  a  positive  diagnosis,  two  courses  are  open  to  the 
physician :  The  first  is  to  wait  until  more  distinctive 
symptoms  develop ;  the  second  is  to  proceed  at  once  to 
an  exploratory  operation.  The  first  method,  that  of 
waiting  until  a  positive  diagnosis  can  be  made,  is  the 
one  that  has  been  most  commonly  practiced.     It  is  the 


15 

easy  way,  and  it  is  one  of  the  factors  most  directly 
responsible  for  the  present  enormous  mortality  of  this 
disease.  It  is  in  the  hope  that  this  waiting  method 
may  be  abandoned  that  this  pamphlet  is  prepared  for 
publication. 

EXPLORATORY     OPERATIONS 

Diagnosis  by  exploratory  operation  is  the  method 
which  promises  the  greatest  and  most  immediate  reduc- 
tion of  the  mortality  of  cancer.  The  exploratory  oper- 
ation must  be  adapted  to  the  region  or  organ  affected 
by  the  disease,  and  it  must  be  emphasized  that  a  pro- 
cedure which  is  suitable  in  one  situation  may  be 
extremely  dangerous  in  another.  The  desirability  of 
an  early  exploratory  operation,  therefore,  varies  with 
the  situation  of  the  disease. 

BIOPSY 

The  operative  removal  of  tissue  for  pathologic  exam- 
ination (biopsy)  is  a  measure  open  to  discussion. 
Where  a  positive  diagnosis  can  be  made  without  this 
aid,  the  best  and  safest  treatment  is,  undoubtedly,  to 
proceed  at  once  to  immediate  radical  operation.  To  cut 
into  cancer  tissue  "in  situ,"  undoubtedly  adds  to  the 
danger  of  dissemination  of  the  disease.  In  certain 
regions,  however,  the  radical  operation  for  cancer 
involves  such  great  operative  risk  and  such  serious 
mutilation,  that  it  cannot  with  justice  to  either  patient 
or  physician  be  advised  on  anything  but  a  positive 
diagnosis.  In  this  class  fall  especially  cancer  of  the 
larynx,  cancer  of  the  tongue  and  jaw,  and  spindle  cell 
sarcoma  of  the  long  bones.  Under  these  conditions, 
especially  if  the  tumor  is  an  ulcerated  one,  the  removal 
of  a  superficial  fragment  for  immediate  frozen  section 
diagnosis  is  held  to  be  permissible,  although  no  delay 
should  be  tolerated,  and  the  radical  operation  should  be 
completed  under  the  same  anesthesia.  Many  surgeons 
believe  that  in  such  an  exploratory  operation  the  wound 
in  the  suspected  cancer  tissue  should  be  immediately 
and  thoroughly  cauterized  to  prevent  the  operative 
implantation  of  living  cancer  cells  during  the  subse- 
quent stages  of  the  operation. 

The  safest  procedure  to  be  followed  in  doubtful  or 
suspected  cases  of  cancer  in  each  organ  or  situation  is 


16 

discussed  in  the  subsequent  sections  of  this  pamphlet. 
It  is  sufficient  here  to  urge  on  the  practicing  physician 
the  dangers  of  delay,  and  the  advantages  to  the  patient 
of  an  early  positive  diagnosis. 

EARLY    OPERATION     OFFERS     THE     BEST     PROSPECT 
OF     CURE 

It  is  the  well  established  opinion  of  the  best  medical 
authorities  that  at  the  present  day  early  and  thorough 
operative  removal  of  the  primary  tumor  offers  the 
most  certain  cure  for  cancer.  Other  methods  of  treat- 
ment are  of  value  in  incurable  cases,  but  to  obtain  a 
sure  and  complete  cure  of  the  disease  the  original  focus 
must  be  eradicated,  together  with  all  of  the  tissues 
which  are  known  in  each  region  to  be  the  ones  earliest 
invaded  with  the  beginning  of  extension  of  the  dis- 
ease. When  the  disease  can  be  recognized  in  its  early 
stages,  and  this  thorough  and  complete  operation 
promptly  performed,  the  patient  should,  theoretically, 
be  cured  of  cancer  with  almost  as  great  certainty  as  a 
cure  can  be  obtained  in  cases  of  appendicitis.  Twenty 
years  ago  the  early  signs  of  appendicitis  were  little 
known.  Cases  came  late  into  the  hands  of  the  surgeon, 
and  the  mortality  was  enormous  in  comparison  to  that 
of  the  present  day  when  the  public  and  the  physician 
both  recognize  the  importance  of  early  operation.  It 
is  surely  not  too  much  to  hope  that  a  similar  reduction 
in  the  mortality  of  many  of  the  more  favorable  forms 
of  cancer  will  take  place  when  the  imperative  need  of 
early  operation  for  this  disease  is  better  understood. 

CONDITIONS     ESSENTIAL     TO     EARLY     OPERATION 

1.  The  Patient. — The  first  essential  in  procuring 
prompt  treatment  of  cancer  cases  is  that  the  lay  public 
should  be  educated  to  understand,  as  they  now  under- 
stand in  the  case  of  appendicitis,  the  need  of  early 
operation,  and  the  importance  of  the  early  recognition 
of  the  disease.  We  live  in  a  period  of  publicity,  and 
medical  matters  are  coming  to  be  recognized  as  one  of 
the  subjects  in  which  greater  public  knowledge  works 
for  the  common  good.  The  American  Society  for  the 
Control  of  Cancer  has  done  a  great  deal  by  circulars, 
public  lectures,  and  by  legislative  and  state  committees, 
to  promote  this  work.    City  and  state  boards  of  health 


17 

and  individual  health  officers  in  special  districts  have 
contributed  the  help  of  their  official  position  to  this 
work,  and  the  daily  press  and  the  magazines  have  given 
their  assistance  in  this  worthy  cause.  A  better  knowl- 
edge of  the  disease  is  already  evident  in  those  districts 
where  this  publicity  work  has  been  carried  on,  but 
much  remains  to  be  done,  and  there  are  many  people 
who  can  be  reached  only  with  difficulty  who  must  rely 
for  instruction  on  the  only  health  officer  with  whom 
they  come  in  contact — the  family  physician.  It  is  on 
him  that  the  duty  finally  rests  to  inform,  to  correct 
misapprehensions  and  obsolete  ideas,  and  to  teach  his 
people  the  early  and  significant  symptoms  of  the  dis- 
ease. Nothing  can  be  accomplished  in  the  individual 
case  until  the  patient  is  sufficiently  alarmed,  by  symp- 
toms he  has  been  taught  to  regard  as  suspicious,  to  con- 
sult his  physician  for  examination  and  advice. 

2.  The  Physician. — It  might  well  be  supposed  that 
as  soon  as  the  patient  consulted  his  physician  his  dis- 
ease would  be  recognized  and  early  and  adequate  treat- 
ment at  once  applied.  Unfortunately  this  is  not  always 
the  case.  Most  of  the  physicians  of  this  country  have 
been  taught  in  their  medical  schools  and  their  text- 
books of  surgery  the  distinctive  and  typical  symptoms 
of  cancer,  and  by  the  extent  to  which  they  are  typical 
they  are  the  symptoms  of  cancer  which  is  no  longer 
early  but  has  already  progressed  to  the  inoperable 
stage.  It  is  the  early  and  uncertain  cases  that  must  be 
recognized  if  any  material  improvement  in  the  mor- 
tality is  to  be  brought  about. 

3.  Examination. — It  would  seem  unnecessary  to  lay 
stress  on  so  elementary  a  method  as  actual  physical 
examination  as  an  aid  to  diagnosis,  were  it  not  for  the 
fact  that  the  neglect  of  a  physical  examination  by  the 
physician  too  often  robs  the  patient  of  his  or  her 
chance  to  obtain  a  cure.  Sometimes  the  examination 
is  abandoned  or  delayed  in  the  mistaken  object  of  sav- 
ing the  patient's  sensibilities.  Sometimes  it  is  neglected 
because  the  physician  is  not  alert  to  the  possible  grave 
significance  of  the  patient's  symptoms.  In  any  case,  it 
may  fairly  be  said  at  the  present  day  that  the  physician 
who  fails,  by  a  physical  examination,  to  make  sure  that 
the  symptoms  complained  of  are  not  due  to  cancer  fails 
to  give  his  patient  the  chance  of  cure  to  which  he  is 


18 

entitled.  Especially  is  this  true  in  cases  of  cancer  of 
the  breast,  of  the  uterus,  and  of  the  rectum,  where  the 
early  diagnosis  depends  entirely  on  physical  examina- 
tion. 

4.  Diagnosis. — If  cancer  is  to  be  detected  in  its  early 
stages  its  earliest  symptoms  must  be  well  known  to  the 
physician,  and  a  large  number  of  doubtful  cases  must 
be  taken  care  of  where  positive  symptoms  are  lacking 
but  a  strong  suspicion  of  cancer  exists.  How  are  such 
cases  to  be  handled?  On  the  one  hand  the  physician 
does  not  wish  to  let  himself  get  the  reputation  of  being 
an  alarmist,  and  drive  his  patients  to  unnecessary  oper- 
ations on  a  mistaken  diagnosis.  On  the  other  hand,  he 
cannot,  for  the  sake  of  the  patient,  wait  for  the  more 
certain  symptoms  to  develop,  and  for  the  disease  in  the 
meantime  to  become  incurable.  It  is  the  physician's 
reputation  against  his  patient's  life.  There  can  be  only 
one  answer — the  life  of  the  patient  is  the  only  consid- 
eration. Under  these  circumstances  the  physician 
deserves  the  aid  and  the  sympathy  of  the  community. 
The  public  must  be  taught  that  the  physician  who  is 
alert  to  recognize  and  procure  operative  treatment  in 
the  early  stages  of  the  disease  will  undoubtedly  at  times 
cause  patients  the  expense  of  an  unnecessary  surgical 
consultation- — an  expense  that  most  persons  will  gladly 
bear  if  they  can  be  assured  that  they  are  not  afflicted 
with  this  terrible  disease.  It  is  the  early  cases  that 
offer  the  difficult  problems,  and  deserve  the  service  of 
the  very  best  experience.  And,  finally,  there  are  very 
few  regions  of  the  body  in  which,  in  a  doubtful  case, 
with  the  laboratory  facilities  of  a  modern  hospital,  an 
exploratory  operation  cannot  be  performed  to  procure 
an  immediate  positive  diagnosis  by  frozen  section 
examination  of  the  suspected  tissues.  The  physician 
who  is  alive  to  his  responsibilities  in  the  early  diagnosis 
of  cancer  and  who  brings  his  patient  to  operation  dur- 
ing the  early  and  uncertain  stages  of  the  disease,  ren- 
ders the  greatest  service  to  his  community,  and  deserves 
that  this  fact  be  recognized. 

5.  Consent  of  Patient  to  Operation. — Granting  that 
the  patient  seeks  early  advice  and  that  the  physician 
recognizes  the  early  symptoms  and  advises  immediate 
operative  treatment,  the  consent  of  the  patient  to  this 
operation  must  be  obtained.    In  the  experience  of  the 


19 


older  members  of  the  community,  and  they  are  the 
ones  concerned  in  the  cancer  problem,  one  after  another 
of  their  friends  and  acquaintances  has  died  of  cancer, 
and  many  of  them  of  recurrence  after  operation.  Is 
it  to  be  wondered  at  that  they  have  little  faith  in  the 
surgical  treatment  of  the  disease?  They  do  not  know 
that  during  the  last  twenty-five  years  the  operations 
for  cancer  of  different  organs  have  been  standardized, 
the  patients  have  been  operated  on  earlier,  and  the 
numbers  of  cures  have  been  materially  increased.  They 
do  not  even  know  of  the  cured  patients  with  whom 
they  come  in  daily  contact,  for  the  cured  patients  do 
not  tell,  and  the  scars  of  operation  are  rarely  visible. 
These  are  some  of  the  facts  about  the  disease  which 
must  be  established  with  the  laity.  Such  facts  are 
given  in  this  pamphlet,  and  may  be  used  with  confi- 
dence by  any  physician  who  wishes  a  fair  statement  of 
the  situation. 


Ill 

"PRECANCEROUS"   CONDITIONS 


One  factor  which  during  the  last  ten  years  has 
proved  to  be  of  great  importance  in  the  origin  of  cancer 
is  the  element  of  chronic  irritation.  As  the  various 
theories  of  the  parasitic  origin  of  cancer  have  been 
disproved,  the  element  of  chronic  irritation  has  been 
found  to  become  an  increasingly  important  factor  in 
the  incidence  of  cancer  in  one  region  after  another. 
This  fact  has  made  it  possible  to  give  prophylactic 
treatment  for  the  purpose  of  preventing  the  occurrence 
of  cancer,  a  procedure  which  is  exactly  as  rational  as 
the  prophylactic  use  of  antitoxins  in  many  of  the  infec- 
tious diseases,  and  in  fact  is  perhaps  a  more  effective 
life-saving  measure.  This  prophylactic  treatment  con- 
sists of  the  removal  by  a  minor  operation,  often  under 
local  anesthesia,  of  lesions  such  as  keratoses,  moles, 
fissures,  chronic  ulcerations  and  indurations,  and  the 
benign  tumors,  which  so  often  precede  the  development 
of  cancer  itself.  This  prophylaxis  further  demands  the 
avoidance  of  sources  of  chronic  irritation,  such  as,  for 
instance,  the  removal  of  an  ill-fitting  tooth  plate  which 
causes  irritation  of  the  gum,  or  the  repair,  at  as  early 
a  date  as  possible,  of  the  deeper  lacerations  of  the 
cervix  which  occur  at  childbirth. 

The  more  important  lesions  which  may  be  regarded 
as  of  precancerous  significance  may  be  summarized  as 
follows : 

1.  Pigmented  moles  have  long  been  recognized  to  be 
the  starting  point  of  that  most  fatal  form  of  malignant 
disease,  the  so-called  melanotic  sarcoma.1  Not  all 
moles,  of  course,  undergo  that  transformation,  but  all 
must  be  held  to  contain  that  inherent  possibility  of 
development,  and  on  the  slightest  sign  of  increase  in 
size,  irritation  or  induration,  they  should  be  widely 
removed  by  radical  operation.  Pigmented  moles  on 
the  hands  and  feet  are  especially  liable  to  repeated 
trauma,  and  thus  to  malignant  change. 

1.  Melanotic  sarcoma  is  believed  by  some  good  authorities  to  be  in 
reality   a   form   of   epithelial   tumor — i.    e.,   carcinoma. 


21 

2.  The  senile  keratoses,  or  scaling  patches  of  heaped 
up  squamous  epithelium,  so  common  on  the  face  and 
exposed  parts  of  the  body  of  those  of  advancing  years, 
are  among  the  most  common  starting  points  for  cancer 
of  the  skin. 

3.  Chronic  ulcers  and  fissures  of  the  skin  due  to  old 
burns  and  scars,  the  effects  of  roentgen  rays  and 
radium,  tuberculosis  of  the  skin,  and  old  syphilitic 
lesions  often  cause  cancer.  To  this  category  belongs 
the  "Kangri"  cancer  of  Kashmir  (squamous  cell  car- 
cinoma of  the  abdominal  wall),  occurring  at  the  site 
of  chronic  ulceration  due  to  burning  from  the  Kangri 
basket,  or  hot  stove  carried  against  the  abdominal  skin 
within  the  clothing  of  the  natives. 

4.  Gallstones  are  accompanied  by  chronic  irritation 
of  the  gallbladder,  and  in  a  certain  percentage  of  cases 
carcinoma  of  the  gallbladder  occurs. 

5.  A  certain  proportion  of  ulcers  of  the  stomach  are 
known  to  become  the  site  of  cancer  of  that  organ,  and 
a  history  which  can  be  interpreted  as  evidence  of  pre- 
vious ulcer  is  obtainable  in  certain  cases  of  gastric 
cancer. 

6.  Erosions  and  lacerations  of  the  cervix  of  the 
uterus,  the  almost  inevitable  result  of  childbirth,  are 
the  most  common  factors  predisposing  to  cancer  of 
the  cervix.  While  it  is  customary  for  the  physician  to 
repair  immediately  the  more  serious  lacerations  of  the 
cervix,  less  extensive  lesions  can  be  detected  only  at  a 
later  period  after  involution  has  occurred.  The  rou- 
tine examination  of  all  women  for  cervical  lesions 
three  months  after  labor  has  been  advocated,  that  these 
lesions  may  be  immediately  repaired,  and  the  predis- 
position to  cancer  avoided.  It  is  advisable  that  all 
women  who  have  borne  children,  as  they  approach  the 
menopause,  should  have  a  vaginal  examination  and  an 
inspection  of  the  cervix  at  reasonable  intervals  until 
the  menopause  is  well  established,  and  the  normal 
atrophic  changes  have  taken  place.  Deep  lacerations 
should  be  repaired,  and  superficial  lesions,  if  resistant 
to  local  treatment,  are  sufficient  indication  for  amputa- 
tion of  the  cervix.  The  hyperplastic  endometritis 
which  accompanies  fibromyoma  of  the  uterus  is  also 
believed  to  be  one  of  the  most  important  predisposing 
causes  of  cancer  of  the  fundus. 


22 

7.  Cystitis  of  one  form  or  another  often  precedes 
cancer  of  the  bladder,  and  the  irritation  of  Bilharzia 
parasites  or  of  specific  chemical  irritants,  such  as 
anilin,  are  recognized  as  producing  changes  in  the  blad- 
der mucosa  which  may  go  on  to  carcinoma. 

8.  Carcinoma  of  the  buccal  mucous  membranes — the 
lip,  tongue,  cheek  and  jaw — have  long  been  associated 
with  one  or  another  source  of  chronic  irritation.  In 
this  country  the  most  common  source  of  chronic  irri- 
tation of  the  buccal  mucous  membranes  is  the  use  of 
tobacco.  It  is  significant,  also,  that  in  other  countries, 
as  the  orient,  cancer  of  the  buccal  mucous  membranes 
appears  to  arise  most  directly  as  the  consequence  of 
the  chewing  of  other  irritants,  such  as  the  buyo  leaf 
or  the  betel  nut.  Syphilis  is  also  a  recognized  predis- 
posing factor  to  cancer  of  the  mouth,  and  the  chronic 
hyperplastic  condition  of  the  buccal  mucous  membrane 
— leukoplakia — has  repeatedly  been  observed  to  prog- 
ress into  carcinoma  while  under  treatment.  The  irri- 
tation of  ill-fitting  tooth  plates,  or  the  chronic  irrita- 
tion of  pyorrhea  alveolaris  occasionally  can  be  recog- 
nized as  forerunners  of  cancer  of  the  alveolar  pro- 
cesses. 

9.  Kraurosis  and  leukoplakia  of  the  vulva  are  forms 
of  superficial  lesions,  benign  in  origin,  which  exhibit 
a  definite  tendency  to  subsequent  malignant  change. 
Suitable  treatment  and  close  and  continued  observa- 
tion to  detect  the  early  signs  of  the  development  of 
cancer  must  not  be  neglected,  in  order  that  radical 
operative  treatment  may  be  instituted  during  the  early 
stages  when  the  disease  can  thus  be  cured. 

10.  Involution  changes  of  a  physiologic  nature 
appear  to  predispose  to  cancer  in  certain  organs, 
notably  the  female  breast,  and  the  male  prostate.  In 
the  breast  the  involution  phenomena  which  give  rise 
to  the  condition  commonly  known  as  chronic  cystic 
mastitis  show  an  incidence  of  carcinoma  estimated  at 
from  10  to  25  per  cent.,  while  in  the  prostate  chronic 
prostatitis  and  hypertrophy  precede  the  symptoms  of 
carcinoma  in  a  notable  proportion  of  all  cases. 

11.  Many  tumors  which  are  essentially  benign  in 
character  have  been  shown  to  be  capable  of  malignant 
transformation,  especially  in  the  later  years  of  life. 
These  include  papillomas,  adenomas  of  the  thyroid  and 


23 

of  the  intestines,  villous  tumors  of  the  bladder,  papil- 
lary and  cystic  tumors  of  the  ovary  and  of  the  breast, 
polyps  of  the  uterus  or  the  rectum,  and,  in  fact,  all 
tumors  in  which  the  epithelial  elements  are  in  pre- 
ponderance. 

In  all  of  the  foregoing  conditions  the  possibility,  if 
not  the  probability,  of  cancerous  transformation  has 
been  shown  to  be  a  serious  element  in  prognosis.  There 
can  be  no  question  that  the  cure  or  the  removal  of  all 
such  lesions  is  a  vital  indication.  Removal  of  the  pre- 
disposing causes  of  cancer,  and  the  early  recognition 
of  cancer,  when  it  is  present,  are  the  two  measures 
which  give  promise  at  the  present  time  of  yielding  the 
greatest  results  in  reducing  the  mortality  of  the  disease. 


IV 

CARCINOMA    OF    DIFFERENT 

ORGANS 


1.    CARCINOMA     OF    THE     EXTERNAL     SKIN 

This  is  a  common  form  of  cancer  found  chiefly 
among  persons  of  advanced  age,  and  on  the  exposed 
parts  of  the  body,  especially  in  those  who  have  long 
followed  outdoor  occupations.  It  is  slow  growing, 
usually  only  locally  invasive  and  malignant,  and  rarely 
produces  remote  metastases.  There  are  two  main 
types :  ( 1 )  those  arising  from  the  differentiated  squa- 
mous cells,  and  (2)  those  originating  from  the  less 
differentiated  basal  cells  of  the  epithelium  and  repro- 
ducing themselves  in  the  form  of  gland  ducts  or  hair 
matrix  cells.  The  squamous  cell  type  is  more  likely  to 
show  extension  to  the  lymphatic  glands  in  the  neigh- 
borhood, but  not,  as  a  rule,  until  late  in  the  course  of 
the  disease.  Carcinoma  of  the  external  skin  is  espe- 
cially liable  to  occur  as  a  secondary  change  in  preexist- 
ing fissures,  keratoses,  and  chronic  ulcerations  and 
indurations. 

Symptoms. — The  development  of  a  tumor  involving 
the  skin,  or  of  a  chronic  ulceration  covered  with  a 
crust  and  presenting  an  indurated  base  and  periphery, 
is  suggestive  of  carcinoma  and  demands  investigation. 
Especially  is  this  true  when  the  lesion  has  been  trau- 
matized or  subjected  to  chronic  irritation. 

Differential  Diagnosis.  —  Differential  diagnosis 
requires  that  syphilis,  tuberculosis,  and  some  of  the 
rarer  forms  of  skin  diseases  be  considered.  In  doubt- 
ful cases  the  operative  excision  of  the  whole  lesion, 
with  a  wide  margin,  and  the  pathologic  investigation 
of  the  tissue,  is  the  safest  course. 

Precancerous  Lesions.  —  Warts,  keratoses  and 
chronic  ulcers,  when  possible,  should  be  excised  or 
destroyed  before  they  have  an  opportunity  to  undergo 
secondary  malignant  changes  and  become  cancer.  This 
can  usually  be  done  by  a  very  minor  operation,  often 
with  local  anesthesia.  Many  of  the  more  superficial 
lesions  of  this  nature  can  safely  be  eradicated  by 
radium,  roentgen  ray  or  even  caustic  applications,  but 


25 

the  clean  surgical  excision  is  undoubtedly  the  safest 
method. 

Standard  Operative  Treatment.  —  The  standard 
operative  treatment  is  total  excision,  with  a  consider- 
able margin  of  healthy  tissue.  Where  extension  to 
neighboring  lymphatic  nodes  is  thought  to  have 
occurred,  dissection  of  the  affected  territory,  with 
removal  of  the  diseased  nodes  and  those  immediately 
beyond  them,  in  one  mass,  should  be  performed.  Super- 
ficial carcinoma  of  the  face,  especially  in  the  region 
of  the  eyelids,  may  be  subjected  to  treatment  with 
roentgen  rays  or  radium,  in  order  that  deforming  scars 
may  be  avoided.  While  less  certain  than  operation, 
treatment  by  radiation  in  suitable  cases  offers  the  pros- 
pect of  a  soft  and  less  conspicuous  scar,  and  the  same 
may  be  said  in  regard  to  the  treatment  of  very  super- 
ficial lesions  with  the  curet  and  caustic  agents,  but 
any  application  of  such  methods,  especially  freezing 
or  electrolysis,  which  does  not  insure  the  destruction 
of  every  malignant  cell,  is  to  be  condemned. 

Results. — Statistics  are  difficult  to  obtain  on  cases 
of  this  character.  On  account  of  the  relative  infre- 
quency  or  retardation  of  metastatic  extension,  cure  by 
early  complete  excision  should  be  obtainable  in  every 
case  of  non-metastasizing  carcinoma  of  the  skin.  It 
is  a  fact,  however,  that  an  incomplete  excision  is  often 
done  in  the  effort  to  remove  no  more  tissue  than  abso- 
lutely needed,  whereas  a  wide  margin  is  essential  to  a 
successful  operation.  In  the  few  cases  which  do  pro- 
duce metastases  the  block  dissection  of  the  regional 
lymph  nodes,  together  with  the  operative  excision  of 
the  tumor  should  yield  a  very  large  percentage  of  cures 
in  early  cases. 

2.    CARCINOMA     OF    THE     LIP 

This  is  one  of  the  more  common  forms  of  squamous 
cell  cancer,  especially  in  men  and  has  been,  attributed 
to  chronic  irritation  such  as  the  use  of  tobacco  in  any 
form,  but  especially  in  pipe  smoking.  It  produces 
metastases  in  submental  or  submaxillary  lymph  nodes, 
after  a  brief  period  estimated  at  two  or  three  months, 
but  less  early  than  in  carcinoma  of  the  tongue  and  jaw. 

Symptoms.— Carcinoma  of  the  lip  occurs  as  an 
indurated  chronic  ulcer  or  non-ulcerated  thickening  on 
the  free  border  of  the  lip;  it  rarely  appears  as  a  warty 
growth. 


26 

Differential  Diagnosis. — Primary  syphilis  (chancre) 
is  rare.  Syphilitic  fissures  are  more  common,  and 
may  accompany  cancer.  A  positive  Wassermann  does 
not  prove  that  cancer  is  not  present,  and  delay  for  a 
therapeutic  test  is  not  advisable. 

Precancerous  Lesions. — Chronic  ulcers  and  scabs 
(keratoses)  are  to  be  regarded  as  precancerous  condi- 
tions, and  should  be  removed  by  excision,  or  in  suit- 
able cases  by  the  use  of  radium.  In  doubtful  cases 
operative  removal  is  to  be  preferred  in  order  that  a 
pathologic  examination  of  the  tissue  may  be  made,  and 
the  radical  dissection  of  the  regional  nodes  performed 
if  a  frankly  malignant  tumor  is  disclosed. 

Standard  Operative  Treatment. —  (1)  Doubtful 
cases :  Excise  with  a  generous  margin,  and  if  the 
microscope  shows  carcinoma  follow  immediately  with 
dissection  and  removal  of  the  lymph  nodes  of  the  sub- 
mental region  and  of  the  submaxillary  region  on  the 
affected  side.  If  the  tumor  is  near  the  middle  line, 
both  submaxillary  regions  should  be  dissected.  The 
whole  of  the  submaxillary  salivary  gland  must  be 
removed.  (2)  If  diagnosis  is  certain,  excision  by 
broad  margin  and  dissection  of  lymph  nodes,  as  above 
is  indicated. 

Results. — Cancer  of  the  lip  recognized  and  oper- 
ated upon  in  its  early  stages  at  the  time  when  the 
lymph  nodes  are  not  yet  involved  yields  a  high  per- 
centage of  radical  cures  of  the  disease.  The  more 
extensive  the  glandular  involvement,  the  less  the  pros- 
pect of  success  with  operative  treatment.  Many  cases 
are  allowed  to  become  inoperable  by  neglect  of  the 
regional  neck  dissection  at  the  primary  operation. 

3.  CARCINOMA  OF  THE  TONGUE,  MOUTH  AND  JAW 

These  growths  are  not  rare,  and  are  one  of  the  most 
malignant  of  the  accessible  forms  of  carcinoma.  They 
are  of  the  squamous  cell  type,  producing  early  metas- 
tases to  the  submental,  submaxillary,  parotid,  and 
carotid  nodes,  and  spreading  rapidly  by  local  invasion 
into  the  adjacent  tissues  of  the  floor  of  the  mouth  and 
across  to  the  other  side  of  the  tongue,  mouth  and  neck. 
The  influence  of  tobacco  as  a  form  of  chronic  irrita- 
cion  is  held  to  be  of  serious  importance  in  the  origin 
of  cancer  in  this  locality. 


27 

Symptoms. — This  type  of  carcinoma  begins  as  an 
indurated  ulcer  or  thickening  of  the  mucous  membrane 
of  the  tongue  or  mouth,  or  on  the  alveolar  border  of 
the  gum.  Any  such  ulcer  of  two  weeks'  duration 
should  be  regarded  with  suspicion. 

Differential  Diagnosis. — Chronic  inflammatory  con- 
ditions, such  as  ulcers  due  to  jagged  teeth,  ill-fitting 
tooth  plates,  pyorrhea,  etc.,  may  be  predisposing 
causes.  Late  syphilis  is  often  followed  by  carcinoma 
and  a  positive  Wassermann  test  does  not  exclude  car- 
cinoma. Leukoplakia,  or  superficial  milky  glossitis,  is 
also  a  predisposing  cause.  Tuberculosis  has  typical 
punched  out  and  undermined  ulcer,  and  is  generally 
secondary  to  other  tuberculosis.  Actinomycosis  of  the 
jaw  is  rare;  it  is  suppurative,  and  does  not  extend  to 
the  lymph  nodes. 

Precancerous  Lesions. — To  avoid  delay,  doubtful 
cases  are  best  handled  by  excision  of  the  whole  lesion 
for  microscopic  diagnosis  with  cauterization  to  seal  the 
lymphatics.  In  operable  cases  avoid  removal  of  a 
single  lymph  node  from  the  neck  for  diagnosis,  as  such 
an  incomplete  operation  almost  invariably  leads  to  local 
implantation  if  cancer  is  present  in  the  node. 

Standard  Operative  Treatment. — Standard  oper- 
ative treatment  demands  removal  of  practically  the 
whole  tongue,  together  with  the  floor  of  the  mouth, 
and  block  dissection  of  all  lymphatic  tissues  of  one  or 
both  sides  of  the  neck,  usually  including  the  jugular 
vein  and  the  greater  part  of  the  sternomastoid — a  very 
serious  operation.  If  the  jaw  is  divided,  or  removed, 
as  is  necessary  in  many  cases,  the  mortality  is  esti- 
mated to  be  25  to  30  per  cent,  owing  to  pneumonia  or 
mediastinal  sepsis.  The  operation  can  be  done  in  two 
stages  (Whitehead,  Crile)  with  less  mortality  and 
slightly  less  prospect  of  cure  on  account  of  the  danger 
of  local  implantation. 

Residts. — Only  moderately  good  results  are  claimed 
for  operation  in  the  larger  clinics.  In  cases  that  are 
recognized  early,  and  where  the  patient's  constitution 
is  such  as  to  withstand  the  severe  operation,  a  higher 
probability  of  cure  may  be  expected,  but  in  advanced 
cases  the  chances  of  cure  by  operation  become 
extremely  slight. 


28 

4.    CARCINOMA     OF     THE     LARYNX 

This  is  not  an  unusual  form  of  carcinoma,  affecting 
males  more  than  females,  generally  in  the  later  decades 
of  life.  Carcinoma  of  the  larynx  occurs  especially  in 
two  regions:  (a)  in  the  region  of  the  vocal  cords,  and 
(b)  in  the  upper  part  of  the  larynx. 

Symptoms. — Hoarseness  and  loss  of  voice  are  the 
characteristic  symptoms ;  later  dysphagia  and  pain  may 
appear,  and  when  persisting  beyond  a  reasonable  length 
of  time  demand  investigation  with  the  laryngoscope. 
The  growth  may  assume  one  of  several  forms,  some- 
times as  a  localized  hyperemia,  sometimes  as  a  distinct 
growth,  and  sometimes  as  a  deep-seated  infiltration, 
later  becoming  ulcerated,  and  surrounded  by  hyperemia 
and  edema.  Extension  to  the  regional  lymph  nodes 
generally  occurs  late  in  tumors  of  the  larynx,  later 
when  the  tumor  is  in  the  region  of  the  vocal  cords 
than  when  in  the  upper  parts. 

Differential  Diagnosis. — Carcinoma  of  the  larynx 
must  be  differentiated  from  benign  tumors  (papilloma, 
fibroma,  etc.)  of  the  larynx,  and  from  syphilitic,  tuber- 
culous and  other  ulcerations.  Removal  of  tissue  for 
pathologic  examination  (biopsy)  should  seldom  be 
practised,  unless  immediately  followed  by  the  radical 
operation.  It  should  be  avoided  if  the  diagnosis  can 
be  made  with  reasonable  certainty. 

Standard  Operative  Treatment. — Thyrotomy  with 
removal  of  the  disease  and  of  all  adjacent  tissues  has 
given  successful  results  in  early  cases,  especially  in 
cancer  of  the  vocal  cords.  As  a  rule  total  laryngec- 
tomy with  wide  dissection  of  the  regional  nodes  is  the 
operation  of  choice.  The  operative  mortality  is  con- 
siderable, due  to  infection  of  the  air  passages,  and  the 
mutilation  is  often  serious,  but  is  preferable  to  the 
otherwise  certain  fatal  issue.  Palliative  tracheotomy 
and  gastrotomy  may  be  done,  and  radium  and  roentgen 
ray  may  prolong  life  and  relieve  pain  for  a  limited 
period.  The  application  of  radium  before  and  after 
the  removal  of  the  larynx  has  given  good  results. 

Results. — Early  partial,  and  later  total  operations 
have  yielded  many  successful  results,  but  the  prognosis 
in  any  but  early  cases  is  very  grave. 


29 

5.    CARCINOMA     OF     THE     THYROID 

This  is  one  of  the  less  common  forms  of  cancer,  but 
is  liable  to  occur  especially  as  a  late  change  in  thyroid 
tumors  of  long  duration  which  have  previously  been 
considered  to  be  benign  in  character.  Several  types 
are  recognized.  The  tendency  to  remote  metastases 
in  the  lung,  and  especially  in  the  long  bones  and  skull 
is  to  be  borne  in  mind,  even  in  tumors  in  which  the 
histologic  picture  shows  only  adenomatous  tissue 
(malignant  adenoma). 

Symptoms. — An  irregular  nodular  tumor  of  the 
thyroid,  showing  early  fixation  by  adherence  to  sur- 
rounding structures,  involvement  of  the  recurrent 
laryngeal  nerve,  and  extension  to  regional  (jugular) 
lymph  nodes. 

Differential  Diagnosis. — Typical  cases  are  recog- 
nized only  by  symptoms  of  irregular  induration,  fixa- 
tion, nerve  involvement,  dysphagia  and  dyspnea,  which 
indicate  an  incurable  condition.  Early  cases  are  recog- 
nized only  as  tumors  of  the  thyroid  of  unknown  nature, 
cut  are  sufficient  indication,  after  the  age  of  35,  to 
demand  radical  operative  treatment. 

Precancerous  Lesions. — Any  rapidly  growing  thy- 
roid tumor  in  an  individual  of  35  or  over  should  be 
looked  on  with  suspicion. 

Standard  Operative  Treatment.  —  The  standard 
treatment  for  carcinoma  of  the  thyroid  is  radical 
thyroidectomy  to  the  extent  of  total  removal  of  the 
whole  gland  and  of  the  adjacent  lymph  bearing  tissues 
on  both  sides  of  the  neck.  Thyroid  extract  may  be 
administered  to  prevent  myxedema,  and  parathyroidin 
has  been  recommended  to  prevent  tetany  from  removal 
of  the  parathyroids. 

Residts. — Favorable  results  are  obtained  only  in 
early  cases  before  the  capsule  is  invaded,  and  while 
the  diagnosis  is  most  uncertain.  Prophylactic  treat- 
ment by  removal  of  benign  tumors  is  the  most  effective 
measure. 

6.    CARCINOMA     OF    THE     ESOPHAGUS 

This  is  a  squamous  cell  and  metastasizing  carcinoma. 
It  is  rare  and  possibly  related  to  chronic  irritation. 
There  are  an  equal  number  of  cases  among  males  and 
females. 


30 

Symptoms. — The  first  symptoms  are  usually  dys- 
phagia followed  by  progressive  extension  to  the  local 
lymphatics  in  the  neck  or  mediastinum,  local  invasion 
of  the  trachea,  or  perforation  into  the  pleura.  The 
patient  suffers  gradual  starvation. 

Differential  Diagnosis.  —  This  type  of  carcinoma 
must  be  differentiated  from  benign  strictures  and 
pouches  by  esophagoscopy,  bougies,  and  roentgen  rays. 

Doubtful  Cases. — These  must  be  diagnosed  by 
esophagoscopy. 

Standard  Operative  Treatment. — Radical  operation 
is  still  in  the  experimental  stage.  Palliative  operations 
— gastrostomy,  jejunostomy — may  be  performed,  or 
radium  applications  may  be  used. 

Results. — These  cases  are  practically  always  fatal. 

7.    CARCINOMA     OF     THE     STOMACH 

Carcinoma  of  the  stomach  is  one  of  the  most  com- 
mon manifestations  of  the  disease.  It  is  the  most  com- 
mon form  of  cancer  in  males,  and  is  only  exceeded  in 
frequency  in  females  by  cancer  of  the  uterus  and  of 

the  breast. 

Symptoms. — The  symptoms  of  cancer  of  the  stom- 
ach are  insidious.  The  patient  appreciates  only  a 
progressive  disturbance  of  gastric  digestion,  with  loss 
of  weight,  and  increasing  gastric  distress.  These  symp- 
toms sometimes  follow  the  symptoms  of  long  standing 
gastric  ulcer — pain,  hyperacidity,  and  the  appearance 
of  blood  in  the  vomitus  or  in  the  stools. 

Differential  Diagnosis. — The  differential  diagnosis  of 
any  but  advanced  cases  can  be  made  only  with  the  aid 
of  the  laboratory  analysis  of  the  gastric  contents,  and 
the  use  of  the  roentgen  ray. 

Standard  Operative  Treatment. — The  standard  oper- 
ative treatment  of  cancer  of  the  stomach  is  by  excision 
of  the  affected  portion  of  the  stomach  with  the  adja- 
cent lymph  nodes.  Only  a  small  proportion  of  the 
cases  submitted  to  operation  are  sufficiently  early  to 
permit  an  attempt  at  radical  cure. 

Results. — By  a  judicious  selection  of  cases  suitable 
for  radical  treatment  the  operative  mortality  has  been 
much  reduced.  In  cases  which  are  thus  favorable  for 
operation,  cure  of  the  disease  is  claimed  in  a  large 


31 

percentage  in  certain  clinics.  In  general  practice,  how- 
ever, the  figures  are  very  much  lower,  and  where  the 
disease  has  developed  to  the  extent  of  producing  char- 
acteristic symptoms  the  outlook  is  distinctly  unfavor- 
able. 

8.    CARCINOMA     OF     THE     COLON 

This  is  one  of  the  common  forms  of  cancer  in  elderly 
persons. 

Symptoms.  —  The  symptoms  are  insidious — vague 
intestinal  indigestion  and  discomfort  and  loss  of  weight 
in  the  early  stage's.  The  symptoms  become  more  pro- 
nounced as  the  tumor  produces  intestinal  obstruction, 
with  distension,  colicky  pains,  and  blood  in  the  stools. 
As  a  last  stage  the  intestinal  obstruction,  which  was 
chronic  and  partial  in  the  beginning,  may  become  com- 
plete and  thus  acute,  with  fecal  vomiting,  distension 
and  severe  toxemia. 

Differential  Diagnosis.- — This  requires  that  the  causes 
of  benign  obstruction — scars,  ulcers,  the  pressure  of 
benign  tumors  outside  of  the  intestine,  inflammatory 
conditions,  diverticulitis  or  appendicitis  and  the  vari- 
ous forms  of  acute  intestinal  obstruction  should  be 
eliminated.  This  can  be  done  only  by  exploratory  oper- 
ation. The  use  of  roentgen  rays  is  of  assistance  in 
the  more  chronic  cases,  and  the  examination  with  the 
proctoscope  is  of  value  in  the  upper  rectum  and  sig- 
moid cases. 

Doubtful  Cases. — An  exploratory  laparotomy  with 
an  intestinal  anastomosis  or  a  colostomy,  followed  later 
by  removal  of  the  affected  bowel,  is  the  procedure  to 
be  advised. 

Standard  Operative  Treatment. — The  standard  oper- 
ative technic  consists  of  removal,  by  a  wide  margin, 
of  the  affected  bowel  and  its  adjacent  lymph  nodes. 
If  the  disease  is  already  in  the  liver,  radical  cure  is 
not  to  be  attempted.  In  advanced  cases  palliative 
treatment  by  anastomosis  is  of  great  relief  to  the 
patient. 

Residts. — On  account  of  the  difficulty  of  early  diag- 
nosis, few  cases  are  suitable  for  an  attempt  at  radical 
cure.  As  patients  present  themselves  at  a  general  hos- 
pital the  prospect  of  cure  is  distinctly  unfavorable, 
although  successful  cases  are  obtained  from  time  to 
time. 


32 

9.    CARCINOMA      OF      THE      PANCREAS,      GALLBLADDER 
AND      LIVER 

(a)  Pancreas. — Carcinoma  of  the  pancreas  is  rare. 

Symptoms. — These  are  chronic,  progressive,  pain- 
less jaundice,  accompanied  by  loss  of  weight,  distur- 
bance of  digestion,  and  fatty  stools.  The  gallbladder 
is  usually  distended. 

Differential  Diagnosis. — Eliminate  other  causes  of 
obstruction  of  the  common  gallduct,  such  as  that  due 
to  a  gallstone,  or  lymph  nodes  (lymphoma),  or  cancer 
in  the  region  of  the  common  duct  and  chronic  pan- 
creatitis. 

Doubtful  Cases. — Exploratory  operation  is  indicated, 
but  radical  cure  of  cancer  of  the  pancreas  has  not  been 
accomplished. 

Standard  Operative  Treatment. — Palliative  opera- 
tions by  establishing  an  anastomosis  between  the  gall- 
bladder and  the  duodenum,  or  small  or  large  intestine, 
give  temporary  relief  to  one  of  the  most  distressing 
symptoms — jaundice. 

Results. — Patients  may  be  relieved  of  distressing 
symptoms  by  palliative  operations,  but  radical  cure  of 
the  disease  has  not  been  claimed. 

(b)  Gallbladder. — Carcinoma  of  the  gallbladder  is 
rare. 

Symptoms.— The  symptoms  are  indefinite.  There  is 
usually  a  history  of  gallstone  attacks  of  long  duration. 

Differential  Diagnosis. — The  differential  diagnosis  is 
between  cancer  of  the  liver  or  stomach  and  gallstone 
disease.  This  is  rarely  accomplished  except  by  opera- 
tion. 

Doubt  fid  Cases. — It  is  a  well  established  fact  that 
cancer  of  the  gallbladder  is  to  be  feared  in  cases  of 
long  standing  gallstone  disease.  For  that  reason,  in 
cases  of  gallstones,  removal  of  the  gallbladder  is 
becoming  the  operation  of  choice. 

Standard  Operative  Treatment. — When  cancer  of 
the  gallbladder  is  evident,  and  its  extension  to  the  liver 
has  not  occurred,  removal  of  the  gallbladder  is  the 
standard  operation. 

Results. — A  certain  number  of  cases  of  cure  of 
cancer  of  the  gallbladder  have  been  reported.     The 


33 

disease  extends  very  rapidly,  however, .  to  the  liver, 
and  when  this  has  occurred  a  cure  is  not  to  be 
expected. 

(c)  Liver. — Cancer  of  the  liver  is  very  common  as 
a  secondary  manifestation  of  cancer  anywhere  in  the 
intestinal  tract,  and  in  some  cases  of  cancer  of  other 
organs,  such  as  the  breast  or  prostate,  melanotic  sar- 
coma and  other  forms  of  sarcoma.  Primary  cancer  of 
the  liver  is  extremely  rare,  and  so  are  other  primary 
malignant  tumors  of  the  liver,  such  as  hypernephroma. 

Differential  Diagnosis.- — -This  depends,  as  a  rule,  on 
recognition  of  a  possible  primary  focus  of  cancer  else- 
where. 

Standard  Operative  Treatment. — There  is  no  opera- 
tive treatment. 

10.    CARCINOMA     OF    THE     RECTUM 

This  is  a  common  form  of  cancer  and  especially  one 
which  is  prone  to  occur  not  only  in  those  of  cancer  age 
but  in  younger  persons  also. 

Symptoms. — Tenesmus,  bloody  stools,  loss  of  weight, 
and  finally  intestinal  obstruction  are  symptoms  of  car- 
cinoma of  the  rectum. 

Differential  Diagnosis. — Syphilis,  tuberculosis  and 
extensive  chronic  inflammatory  processes  with  fistulae, 
must  be  considered.  Digital  and  proctoscopic  exam- 
ination is  imperative. 

Doubtful  Cases. — Benign  polyps  of  the  rectum  and 
chronic  inflammatory  conditions  must  be  regarded  as 
predisposing  to  cancer  of  the  rectum  and  should 
receive  appropriate  treatment.  Many  cases  of  cancer 
of  the  rectum  are  not  recognized  in  their  early  stages 
because  the  physician  neglects  to  insist  on  a  digital  or 
proctoscopic  examination.  Excision  of  fragments  of 
tumor  tissue  for  pathologic  examination  is  in  general 
to  be  condemned,  but  may  occasionally  be  necessary 
for  diagnosis  and  should  be  made  at  the  time  of  oper- 
ation. 

Standard  Operative  Treatment. — This  consists  in  the 
removal  of  the  whole  rectum  and  the  pelvic  lymphatic 
tissue  on  account  of  the  disposition  of  the  disease  to 
spread  in  the  coats  of  the  intestine  as  well  as  to  the 
lymph  nodes.  This  is  usually  done  by  a  two-stage 
operation — a  primary  colostomy,  with  examination  of 


34 

the  liver  and  of  the  pelvic  lymph  nodes ;  and  the  sec- 
ondary removal  of  the  tumor  and  a  wide  margin  of 
the  adjacent  rectum  by  the  Kraske  incision  or  by  the 
combined  abdominoperineal  route. 

Results. — In  early  cases  successful  results  from  rad- 
ical operation  may  be  expected.  There  is  an  inevitable 
operative  risk  on  account  of  the  severity  of  the  opera- 
tion but  when  the  constitutional  condition  is  good  and 
the  disease  has  not  had  time  to  become  too  far 
advanced  a  reasonable  percentage  of  cases  should  be 
successful. 

11.  CARCINOMA  OF  THE  BLADDER  AND  PROSTATE 

(a)  Bladder. — This  is  one  of  the  rarer  forms  of 
cancer.  It  occurs  in  males  and  females.  It  often 
develops  in  the  base  of  a  supposedly  benign  papilloma. 

Symptoms. — Frequency  of  micturition,  bloody  urine 
and  tenesmus  are  symptoms  of  this  condition. 

Differential  Diagnosis. — This  is  made  by  cystoscope. 
Tuberculosis,  calculus,  bilharzia,  and  blood  from  renal 
tumors  and  calculi  must  be  excluded. 

Doubtful  Cases. — The  precancerous  conditions  are 
chiefly  benign  tumors  and  calculi. 

Standard  Operative  Treatment.  —  Transperitoneal 
operation  with  removal  of  the  affected  portion  of  the 
bladder  is  the  standard  operation  for  radical  cure. 
Where  this  is  not  possible,  intravesical  operations  with 
the  use  of  the  cautery,  radium  or  fulguration  may  be 
attempted. 

Results. — A  considerable  number  of  successful  cases 
of  transperitoneal  operation  have  been  recorded.  The 
use  of  radium  or  other  cauterizing  agents,  however, 
can  at  present  be  considered  only  as  palliative  mea- 
sures, although  there  is  reason  to  hope  that  better 
results  may  ultimately  be  obtained  with  radium. 

(b)  Prostate. — Cancer  of  the  prostate  is  one  of  the 
rarer  forms  of  cancer. 

Symptoms. — These  are  not  materially  different  from 
those  of  prostatic  hypertrophy — i.  e.,  frequency  of 
micturition,  loss  of  power  of  stream,  increasing  to 
retention  of  urine,  blood  in  the  urine,  tenesmus. 

Differential  Diagnosis. — This  depends  on  the  stony, 
hard  and  irregularly  nodular  feel  of  the  prostate  on 


35 

rectal  examination.  Positive  diagnosis  can  only  be 
made  by  microscopic  examination  of  excised  prostate. 

Doubtful  cases. — These  should  be  treated  by  pros- 
tatectomy. Only  early  cases  can  be  cured  by  opera- 
tion. In  advanced  cases  radium  may  give  some  relief 
to  symptoms. 

Standard  Operative  Treatment. — The  standard  oper- 
ation is  prostatectomy — suprapubic  or  perineal. 

Results. — The  radical  cure  of  cancer  of  the  prostate 
by  operation  is  virtually  confined  to  cases  of  prostatic 
hypertrophy  in  which  prostatectomy  has  been  done, 
and  the  early  changes  of  carcinoma  have  been  discov- 
ered only  by  the  pathologic  examination  of  the  tissue. 
In  certain  clinics  the  treatment  of  cancer  of  the  pros- 
tate by  radium  is  claimed  to  have  yielded  more  satis- 
factory results. 

12.    CARCINOMA     OF     THE    UTERUS 

This  is  the  commonest  form  of  cancer  in  the  female. 
There  are  two  varieties:  (a)  carcinoma  of  the  cervix 
(b)  carcinoma  of  the  body. 

(a)  Carcinoma  of  the  Cervix. — This  is  the  squamous 
cell  type  of  carcinoma.  It  almost  always  occurs  in 
women  who  have  borne  children,  and  especially  if  the 
cervix  has  been  lacerated  and  the  lacerations  have 
been  neglected  or  have  become  eroded,  or  subject  to 
constant  irritation. 

Symptoms. — Earliest  symptom  is  a  bloody  discharge 
not  related  to  catamenia,  or  appearing  after  the  meno- 
pause; any  change  in  the  character  of  the  discharge, 
especially  if  it  becomes  more  profuse,  more  foul,  or 
more  irritating;  or  if  it  appears  irregularly  after  exer- 
tion, straining  at  stool,  the  use  of  a  douche  or  after 
intercourse  indicates  carcinoma  of  the  cervix.  The 
appearance  of  a  discharge  even  though  not  bloody  in 
character,  after  a  period  of  freedom  from  discharge, 
should  be  regarded  as  a  suspicious  symptom.  An 
examination  shows  an  indurated  excoriation  or  ulcera- 
tion of  the  cervix  which  may  be  within  the  os.  Later 
there  may  be  deep  infiltration  or  a  productive  cauli- 
flower growth,  with  ulceration,  bleeding  and  offensive 
discharge.  It  extends  early  to  tissues  of  broad  liga- 
ments and  vaginal  wall  by  direct  extension,  and  to 
pelvic  lymph  nodes. 


36 

Differential  Diagnosis. — The  early  diagnosis  of  can- 
cer of  the  uterus  demands  an  early  digital  and  visual 
examination.  Too  often  the  disinclination  of  the 
patient  and  the  indifference  of  the  physician  combine 
to  postpone  this  examination  until  too  late  for  cure 
of  the  disease.  Early  cases  can  be  distinguished  from 
nonmalignant  ulcerations  and  lacerations  only  by 
microscopic  examination. 

Doubtful  Cases. — Lacerations  due  to  childbirth  form 
the  precancerous  condition.  For  this  reason  all  lacera- 
tions should  be  excised  and  repaired  as  prophylaxis, 
at  least  as  soon  as  the  probability  of  further  child- 
bearing  is  over.  Some  surgeons  advocate  the  high 
amputation  of  the  cervix  in  suspected  cases,  while 
others  go  so  far  as  to  advise  an  immediate  hysterec- 
tomy, without  the  preliminary  removal  of  tissue  for 
pathologic  confirmation  of  the  diagnosis. 

Standard  Operative  Treatment.  —  For  established 
carcinoma  of  the  cervix  of  the  uterus  the  standard 
operation  is  total  hysterectomy  with  the  removal  of 
the  pelvic  areolar  tissues  and  lymph  nodes.  This  is  a 
very  serious  operation,  and  the  results,  except  in  very 
early  cases,  have  been  rather  unsatisfactory.  On  this 
account  efforts  have  been  made  in  many  clinics  to  com- 
bine the  use  of  radium  with  a  subsequent  radical  oper- 
ation. Time  has  not  elapsed  at  this  present  writing 
to  permit  a  final  judgment  of  the  value  of  this  com- 
bined method  of  treatment.  For  inoperable  cases,  how- 
ever, treatment  with  radium  gives  most  satisfactory 
palliative  results,  and  in  a  few  instances  apparent  free- 
dom from  disease  has  been  obtained.  The  actual 
cautery  is  also  employed  in  the  treatment  of  inoper- 
able cases,  as  well  as  caustic  applications.  Such  mea- 
sures, however,  are  only  palliative. 

Results. — In  advanced  cases  the  results  of  radical 
operation  for  cancer  of  the  cervix  are  very  unsatisfac- 
tory. In  early  cases  a  reasonable  percentage  of  cures 
have  been  reported.  The  disease  when  established  is 
one  of  the  most  unsatisfactory  forms  of  cancer  for 
operative  treatment,  and  the  mortality  of  the  radical 
operation  is  a  serious  consideration. 

(b)  Carcinoma  of  the  Body  of  the  Uterus. — Adeno- 
carcinoma is  much  rarer  than  that  of  the  cervix,  and 
more  insidious. 


3/ 

Symptoms. — These  are  discharge  of  blood  or  blood)' 
serum  independent  of  catamenia,  or  after  menopause 
and  enlargement  of  the  uterus. 

Differential  Diagnosis. — Conditions  to  be  considered 
in  the  differential  diagnosis  are  hyperplastic  endome- 
tritis, polyps,  cervical  carcinoma,  chorio-epithelioma.  It 
may  occur  in  cases  of  fibromyoma.  Diagnosis  is  ordi- 
narily determined  by  curettage  and  examination  of 
tissue,  although  many  surgeons  believe  it  safer  to  avoid 
the  chance  of  setting  free  cancer  cells  in  the  blood  and 
lymph  vessels  by  curettage,  and  to  proceed  at  once  to 
a  total  hysterectomy. 

Doubtful  Cases. — These  are  especially  fibromyomas 
and  hypertrophic  and  other  forms  of  endometritis. 

Standard  Operative  Treatment. — Panhysterectomy 
with  removal  of  both  ovaries  and  tubes,  and  the  pelvic 
areolar  tissue  and  neighboring  lymph  nodes  is  the 
standard  operative  treatment. 

Results. — Prognosis  for  cure  in  cancer  of  the  fundus 
of  the  uterus  is  better  than  that  in  cancer  of  the 
cervix.  If  the  disease  can  be  recognized  before  gen- 
eral extension  to  the  peritoneum  has  taken  place  the 
radical  operation  is  usually  curative,  and  the  symptom 
of  hemorrhage  makes  this  early  recognition  a  possi- 
bility. A  routine  examination  of  all  curettings  occa- 
sionally reveals  an  unexpected  carcinoma. 

13.    CARCINOMA     OF    THE     OVARY 

This  condition  is  not  very  rare.  It  occurs  as  a  sec- 
ondary manifestation  of  otherwise  nonmalignant  cysts, 
and  cystadenomas  of  ovarian  and  parovarian  origin, 
and  as  a  remote  metastatic  implantation  from  carci- 
noma of  other  organs. 

Symptoms. — These  are  abdominal  swelling  and  feel- 
ing of  weight.    They  are  rarely  rapid  in  onset. 

Differential  Diagnosis.  —  Early  carcinoma  of  the 
ovary  can  be  diagnosed  only  by  operation  on  the  sup- 
posed benign  cyst;  late  carcinoma,  after  peritoneal 
involvement,  by  bloody  ascites  and  ovarian  tumor,  or 
exploration. 

Doubtful  Cases. — Exploratory  laparotomy  should  be 
employed.  Precancerous  condition  is  the  benign  ova- 
rian cyst.     All  benign  ovarian  tumors  should,  if  pos- 


38 

sible,   be   removed   unbroken   as    papillary   intracystic 
growths  already  may  be  present. 

Standard  Operative  Treatment. — Ovariotomy  should 
be  done  with  great  care  to  avoid  rupture  of  cyst  and 
dissemination  of  contents.  Both  ovaries  should  be 
removed. 

Results. — Radical  cure  of  carcinoma  of  the  ovary 
when  the  cyst  is  unruptured  and  when  the  total 
removal  of  both  ovaries  can  be  performed,  is  very 
probable.  It  is  the  diagnosis  of  the  condition  which 
is  difficult. 

(Note:  Some  cases  of  ovarian  carcinoma  of  papil- 
lary type  are  of  a  low  degree  of  malignancy,  and  even 
after  laparotomy  has  disclosed  a  widespread  peritoneal 
implantation  they  may  advance  very  slowly.  Under 
radium  and  roentgen-ray  treatment  the  progress  of  the 
disease  may  be  much  retarded.) 

14.    CARCINOMA     OF     THE     BREAST 

This  condition  is  common  in  the  female ;  rare  in  the 
male. 

Symptoms.- — The  earliest  symptoms  are  those  of  a 
tumor  which  is  usually  painless.  The  nipple  may  be 
drawn  in,  or  the  skin  may  early  show  loss  of  mobility 
over  the  tumor,  or  a  definite  adherence  to  it.  This  is 
usually  the  earliest  distinctive  symptom.  Later  the 
tumor  enlarges,  the  axillary  nodes  show  involvement, 
extending  to  the  subclavicular,  the  supraclavicular  and 
the  mediastinal  glands.  Rarely  the  enlargement  of  the 
axillary  nodes  is  the  first  noticeable  symptom  of  the 
disease.  The  tumor  becomes  adherent  to  the  muscles 
of  the  chest  wall,  and  may  pass  by  direct  extension  to 
the  ribs,  sternum,  mediastinum,  or  pleural  cavity,  or 
to  the  other  breast.  Ulceration  may  finally  occur,  or 
the  disease  may  extend  to  the  liver,  spine,  cranial 
cavity,  or  the  long  bones,  such  as  the  femur  and  the 
humerus.  The  "brawny  arm"  of  breast  cancer  is  a 
familiar  late  symptom,  due  to  the  blocking  of  the  veins 
and  lymph  vessels  by  the  axillary  growth. 

Differential  Diagnosis. — Conditions  to  be  considered 
are  benign  tumors  of  the  breast — adenofibroma,  papil- 
lary cystadenoma,  and  other  rare  tumors — cystic  dis- 
ease of  the  breast,  and  chronic  inflammatory  processes, 
such  as  syphilis,  tuberculosis,  or  chronic  abscess  fol- 


39 

lowing  lactation.  The  most  significant  facts  in  the 
diagnosis  of  cancer  are  the  absence  of  pain,  and  the 
early  adherence  of  the  skin  to  the  tumor.  A  lump  in 
the  breast  of  any  woman,  particularly  if  over  the  age 
of  35  years,  must  be  suspected  to  be  cancer  until  path- 
ological proof  of  some  other  disease  is  obtained. 

Precancerous  Conditions. — As  age  advances  prac- 
tically every  one  of  the  supposedly  benign  tumors  and 
diseases  of  the  breast  shows  an  increasing  predisposi- 
tion to  malignant  disease.  Especially  is  this  true  of 
chronic  cystic  growths,  such  as  papillary  cystadenoma. 
Even  the  adenofibromas  of  adolescence  occasionally 
show  subsequent  malignant  characteristics,  either  as 
carcinoma  or  sarcoma.  In  any  case,  benign  breast 
tumors  and  diseases  are  best  removed  by  operation  if 
the  patient  is  over  30  years  of  age. 

Doubtful  Cases. — Cutting  into  normal  tissue  to 
remove  a  suspicious  nodule  in  the  breast,  and  closing 
the  wound  to  wait  a  week  or  ten  days  for  a  micro- 
scopic report,  has  been  found  to  spread  the  disease  and 
to  make  cure  improbable  by  subsequent  radical  opera- 
tion, if  cancer  is  found  to  be  present.  For  this  reason 
the  handling  of  doubtful  cases  is  very  difficult  in  dis- 
eases of  the  breast.  Two  plans  of  procedure  can  be 
recommended  in  doubtful  cases  :  (a)  Incision  may  be 
made  directly  into  the  tumor,  with  removal  of  tissue 
for  frozen  section  diagnosis,  if  necessary,  to  be  fol- 
lowed immediately  by  cauterization  of  the  wound,  and 
by  the  performance  of  the  complete  operation  if  can- 
cer is  discovered.  This  method  of  procedure  is  appli- 
cable only  where  a  sufficient  knowledge  of  gross  path- 
ology, or  the  facilities  for  an  immediate  frozen  section 
diagnosis  are  available,  and  is  recommended  then  only 
in  cases  where,  from  the  clinical  symptoms,  the  proba- 
bilities are  against  rather  than  in  favor  of  the  diag- 
nosis of  cancer,  as  in  the  case  of  women  under  30 
years  of  age.  (&)  In  women  of  more  advanced  years, 
where  the  symptoms  are  suggestive  of  cancer,  the 
safest  procedure  is  to  perform  the  radical  operation  at 
once  without  incision  into  cancer  tissue.  In  some  very 
small,  and  presumably  very  early  cases,  an  amputation 
of  the  breast  and  dissection  of  the  axilla,  without 
removal  of  the  pectoral  muscles,  may  be  permissible, 
but  the  complete  operation  will  be  found  the  safest 
method. 


40 

Standard  Operative  Treatment. — The  standard 
"complete"  operation  for  cancer  of  the  breast  demands 
the  removal  in  one  piece  of  the  whole  breast,  with  the 
skin  over  it,  the  pectoralis  major  and  minor,  and  the 
axillary  contents,  with  the  exception  of  the  axillary 
artery  and  vein,  and  the  brachial  plexus.  Some  sur- 
geons advise  the  supraclavicular  dissection  also.  The 
incisions  for  this  operation  vary,  and  the  defect  to  be 
closed  is  always  large.  If  the  skin  cannot  be  brought 
together  by  plastic  flaps  a  Thiersch  graft  may  be  neces- 
sary. 

Residts. — In  favorable  cases,  with  early  operation,  a 
considerable  percentage  of  cures  may  be  expected.  The 
average  case  that  comes  to  a  general  hospital,  how- 
ever, has  only  a  moderate  chance  of  cure. 

IS.    CARCINOMA     OF     THE     PENIS 

This  condition  is  rare.  It  is  associated  with  chronic 
irritation,  such  as  venereal  warts  or  phimosis. 

Symptoms. — These  are  papillary  or  ulcerated  indu- 
rated tumor,  and  early  extension  to  the  lymph  nodes  of 
either  groin,  or  both. 

Standard  Operative  Treatment. — The  standard  oper- 
ative treatment  is  amputation  of  the  penis,  and  dissec- 
tion of  both  groins.  Prophylaxis,  circumcision,  clean- 
liness and  treatment  of  venereal  warts  and  sores  should 
be  employed. 

Residts. — Early  radical  and  complete  operation  gives 
good  prospects  for  radical  cure. 

16.    CARCINOMA     OF     THE     VULVA 

This  is  the  squamous  cell  type  of  carcinoma.  It  is 
rare  and  almost  entirely  limited  to  women  beyond  the 
menopause. 

Symptoms. — These  are  pronounced  itching,  often  for 
several  years,  before  the  ulcer  appears,  moderate 
bloody  discharge,  in  some  instances  pain  on  urination, 
early  glandular  involvement  of  inguinal  and  femoral 
lymphatics. 

Precancerous  Conditions. — These  are  "kraurosis"  or 
leukoplakia  of  the  vulva.  Treatment  of  these  condi- 
tions by  radiation  may  be  advisable. 


41 

Differential  Diagnosis. — Syphilitic  ulceration,  chan- 
croid, erosions  from  prolapse,  and  polyp  of  urethra 
are  to  be  considered. 

Standard  Operative  Treatment. — Radical  operation 
with  removal  of  vulva,  together  with  all  of  the  deep 
and  superficial  inguinal  and  femoral  lymph  glands  on 
both  sides  is  the  standard  operative  treatment. 

Results. — Only  with  early  and  radical  operation  is 
the  prognosis  even  moderately  good. 


V 
SARCOMA 


Sarcoma  is  a  malignant  tumor  of  connective  tissue 
origin.  Various  types  of  rapidly  growing  connective 
tissue  cells  may  occur,  such  as  large  and  small  round 
cells,  spindle  cells,  giant  cells,  pigment  cells,  cells  of 
the  mucoid  type  found  in  the  umbilical  cord,  lymphoid 
cells,  and  mixtures  of  all  of  these  different  types.  Sar- 
coma may  arise  primarily  in  any  tissue  of  mesenchymal 
origin,  but  in  general  the  subcutaneous  and  submucous 
tissues,  the  fasciae,  the  bones  and  lymph  nodes,  are  the 
more  common  points  of  origin.  Sarcoma  attacks  per- 
sons at  all  times  of  life,  from  infancy  to  old  age.  It 
grows,  as  a  rule,  with  great  rapidity,  as  it  is  abundantly 
supplied  with  blood  vessels.  It  infiltrates  surrounding 
tissues,  and  through  the  blood  vessels  more  than 
through  the  lymphatics,  spreads  to  distant  parts.  So 
far  as  known  there  are  no  presarcomatous  conditions, 
although  trauma  is  believed  by  many  writers  to  have 
significance  in  the  etiology  of  bone  sarcoma.  We  do 
not  know  what  causes  sarcoma,  and  we  can  do  nothing 
to  prevent  its  origin. 

1.    SARCOMA      OF     THE     BONE 

There  are  two  main  varieties :  (a)  spindle  cell,  or 
periosteal  sarcoma;  (b)  giant  cell,  or  other  medullary 
sarcoma. 

(a)  Spindle  cell  or  periosteal  sarcoma  is  a  tumor 
of  extreme  malignancy.  Its  onset  is  insidious;  its 
growth  is  rapid.  Obscure  pain  or  impaired  function 
of  a  limb  is  followed  by  the  development  of  a  swelling 
of  the  bone.  Rarely  a  spontaneous  fracture  is  the  first 
definite  symptom.  Extension  to  the  viscera,  the  lungs, 
the  liver  and  other  organs  may  take  place  at  any  time. 
The  diagnosis  depends  on  the  roentgen  ray  picture, 
which  is  practically  unmistakable.  Treatment  is  by 
early  and  most  radical  operation — amputation.  The 
results  are  very  discouraging,  on  account  of  internal 
metastases.  Treatment  of  inoperable  or  recurrent 
cases  by  radium  or  roenf/  en  ray  yield  very  unsatisfac- 
tory results. 


43 

(b)  Medullary  sarcoma  arises  in  the  bonemarrow, 
and  produces  a  distension  and  thinning  of  the  cortex 
of  the  bone  such  that  spontaneous  fracture  is  very 
common.  The  onset  is  insidious,  and  the  symptoms 
vague.  A  roentgen  ray  is  suggestive,  but  not  always 
to  be  relied  on  with  certainty  to  exclude  bone  cysts 
and  other  benign  lesions.  The  tumor  often  contains 
giant  cells  as  well  as  large  and  small  round  cells,  and 
its  malignancy  is  much  less  than  the  periosteal  type. 
Extension  is  not  so  rapid  and  internal  metastases  are 
not  so  often  found.  Local  excision,  and  even  incision 
and  curettage  have  been  sufficient  to  cure  in  certain 
cases.  Amputation  may  be  necessary,  however,  on 
account  of  the  extent  of  the  tumor,  and  the  impossi- 
bility of  saving  the  vessels  and  nerves  to  the  distal 
part.  The  prognosis  is  much  better  than  with  periosteal 
sarcoma,  although  internal  metastases  occur  in  rare 
cases.  Treatment  by  radium  and  roentgen  ray  gives 
promise  of  benefit  in  certain  cases  of  medullary  sar- 
coma. 

2.    FASCIAL     SARCOMA 

Fascial  sarcoma  is,  as  a  rule,  of  the  spindle  cell  type, 
yet  its  malignancy  is  much  less  than  the  spindle  cell 
sarcoma  of  periosteal  origin.  It  appears  as  a  hard,  well 
defined  tumor  of  the  subcutaneous  tissues,  fixed  to  the 
deeper  structures,  and  generally  of  slow  growth.  Its 
invasive  character  is  not  so  pronounced,  and  its  ten- 
dency to  remote  and  visceral  extension  is  less,  although 
pulmonary  and  hepatic  metastases  do  occur.  Wide 
local  removal  without  incision  of  the  sarcomatous 
tissue  often  cures. 

3.    SARCOMA     OF     THE     SUBCUTANEOUS     TISSUE 

Sarcoma  of  the  subcutaneous  tissues,  and  of  organs 
such  as  the  thyroid,  the  breast,  the  ovary,  the 
uterus,  the  intestine,  etc.,  present  a  varied  cellular  com- 
position, and  a  marked  variation  of  malignancy.  In 
the  breast,  sarcoma  is  usually  of  the  myxomatous  type 
and  of  low  malignancy.  In  the  uterus  and  ovary  it  is 
usually  spindle  cell,  and  also  of  relatively  low  grade 
malignancy,  while  in  the  subcutaneous  tissues  mixed 
cell  or  round  cell  sarcoma,  of  rapid  growth,  great 
infiltrative  power,  and  rapid  visceral  and  cutaneous 
metastases  may  occur.  The  early  symptoms  are  merely 
those  of  a  tumor  of  more  or  less  rapid  growth.    Exten- 


44 

sive  removal  of  any  such  tumor  of  unknown  origin 
should  be  performed  as  early  as  possible,  and  a  wide 
margin  of  healthy  tissue  should  be  included.  Only 
the  microscope  can  indicate  the  exact  nature  of  the 
tumor,  and  an  exploratory  incision  into  the  tumor 
should  be  avoided.  The  close  relation  of  sarcoma  to 
the  blood  vessels  is  well  established,  and  it  is  becom- 
ing more  and  more  a  principle  of  good  surgery  that 
the  possibility  of  artificial  metastases  by  incision  or 
trauma  of  a  tumor,  in  situ,  is  a  measure  to  be  avoided, 
if  the  best  results  are  to  be  obtained.  If  an  explora- 
tory incision  is  absolutely  necessary  it  may  be  per- 
formed with  the  cautery  knife,  in  order  to  seal  the 
blood  vessels  and  lymphatics  at  the  instant  of  their 
division. 

4.    LYMPHOSARCOMA 

A  number  of  tumors,  or  of  diseases  lying  close  to 
the  border  line  between  tumors  and  inflammatory  dis- 
eases, occur  in  the  lymph  nodes.  Among  these  condi- 
tions two  are  of  special  interest:  (a)  malignant  lym- 
phoma; (b)  lymphosarcoma. 

(a)  Malignant  lymphoma  (Hodgkin's  disease). 
This  is  a  disease,  the  nature  of  which  is  still  under 
investigation,  which  starts  with  the  enlargement  of 
one  or  more  lymph  nodes,  and  progresses  to  a  disease 
of  practically  the  whole  lymphoid  apparatus,  with  infil- 
tration, invasion,  and  even  visceral  manifestations 
similar  to  metastases.  Some  authorities  believe  it  an 
infectious  process,  a  granuloma ;  some  believe  it  a  new 
growth.  It  is  possible  that  both  are  correct  and  that 
it  starts  as  the  result  of  an  infectious  or  toxic  agent 
and  progresses  to  the  character  of  a  malignant  tumor. 
The  disease  is  not  uncommon. 

Symptoms. — The  lymph  nodes  of  one  region,  usually 
the  cervical  nodes,  enlarge.  The  disease  rapidly 
extends  to  other  groups  of  lymph  nodes  and  to  the 
visceral  lymphoid  tissue.  Death  is  finally  caused  by 
mechanical  obstruction  to  one  or  another  vital  func- 
tion, generally  the  respiration.  The  diagnosis  is  estab- 
lished by  the  removal  of  one  or  more  of  the  affected 
lymph  nodes,  disclosing  a  tissue  histologically  typical 
of  the  disease. 

Differential  Diagnosis. — Tuberculous  lymphadenitis 
must  be  excluded  by  the  removal  of  a  gland  for  micro- 


45 

scopic  examination,  if  necessary.  Leukemic  enlarge- 
ment of  lymph  nodes  is  recognized  by  the  differential 
blood  examination.  The  blood  picture  of  Hodgkin's 
disease  is  believed  by  certain  writers  to  be  character- 
istic, but  this  is  not  always  to  be  depended  on. 

Treatment. — Radical  surgical  treatment  is  advocated 
by  a  few  authorities,  and  vaccine  treatment  has  been 
tried,  without  much  success.  At  the  present  day  the 
usual  treatment  is  by  roentgen  ray  or  radium,  and  even 
under  this  treatment  the  relief  afforded  is  usually  but 
temporary,  although  life  may  be  made  far  more  com- 
fortable and  may  be  notably  prolonged. 

(b)  Lymphosarcoma. — This  is  a  malignant  tumor, 
made  up  of  large  round  lymphoid  cells.  It  occurs  in 
several  situations,  notably  the  tonsils.  It  is  of  uni- 
centric  origin,  and  from  that  point  it  invades  the  adja- 
cent tissues,  either  directly  into  surrounding  muscles 
and  fasciae  or  systemically  into  regional  lymph  nodes 
and  lymphadenoid  tissue.  Such  tumors  are  rare.  They 
extend  rapidly  to  the  adjacent  lymph  nodes  as  well  as 
through  the  blood  vessels  by  metastases  to  the  viscera. 
They  are  extremely  malignant  tumors,  and  are  rarely 
cured  even  by  the  most  extensive  surgical  operations. 
They  are  sometimes  favorably  affected  by  radiation 
for  a  relatively  brief  period  of  time,  but  this  can  be 
considered  only  a  form  of  palliative  treatment. 

5.    MELANOSARCOMA 

One  of  the  rarer  but  one  of  the  most  malignant 
known  forms  of  sarcoma  is  that  composed  of  cells 
similar  to  the  pigmented  cells  of  the  rete.  mucosum 
—melanotic  sarcoma.  Such  tumors  occur  also  in 
the  retina,  choroid,  and  other  situations  where  pig- 
ment-bearing cells  are  found.  It  is  because  of  the 
occurrence  of  melanosarcoma  in  pigmented  moles  that 
the  universal  rule  for  the  removal  of  such  moles  is 
promulgated.  Melanosarcoma,  in  its  invasive  charac- 
teristics and  in  its  extension  to  adjacent  lymph  nodes, 
resembles  carcinoma  rather  than  sarcoma,  and  some, 
indeed,  believe  that  its  cells  are  of  epithelial  origin. 
In  any  case  it  is  one  of  the  most  rapidly  growing  and 
one  of  the  most  malignant  tumors  with  which  we  have 
to  deal.     When  extension  has  occurred  to  adjacent 


46 

lymph  nodes  a  cure  is  rarely  obtained,  even  by  the 
most  radical  operation.  The  liver  is  early  involved. 
The  disease  must  be  prevented  by  the  removal  of  pig- 
mented moles  by  excision,  before  they  have  undergone 
this  malignant  change,  or,  at  least,  by  their  radical 
removal  together  with  the  regional  lymph  nodes,  on 
the  slightest  sign  of  induration,  ulceration,  or  on  any 
disposition  to  increase  in  size. 


VI 
OTHER    MALIGNANT    TUMORS 


1.    MYELOMA 

Myeloma  is  a  term  applied  to  a  rare  group  of  tumors 
of  the  bone  marrow.  Some  are  local  in  origin,  rapidly 
growing  and  productive  of  wide  metastases,  and  rapidly 
fatal,  while  others  are  more  systemic,  or  multicentric 
in  origin,  and  more  slow  growing,  but  also  generally 
fatal.  Multiple  involvement  of  the  lymph  nodes  occurs 
in  certain  forms  of  the  disease. 

Symptoms. — The  onset  is  obscure — gradually  pain 
and  tenderness  occur  over  certain  bones,  and  later 
definite  local  enlargement  of  the  bone  can  be  recog- 
nized, and  bone  absorption  demonstrated  by  the  roent- 
gen ray.  The  destruction  of  the  cortical  bone  and 
the  occurrence  of  Bence-Jones  albumose  in  the  urine 
are  characteristic  symptoms. 

Diagnosis. — Myeloma  is  to  be  distinguished  from 
the  relatively  benign  giant  cell  medullary  sarcoma  and 
the  bone  metastases  of  hypernephroma  by  microscopic 
sections,  as  well  as  from  bone  cysts,  syphilis,  and  othei 
bone  lesions  by  the  roentgen  ray. 

Treatment. — Only  the  more  local  and  less  malignant 
forms  can  be  relieved  by  radical  operative  removal 
The  more  systemic  type  is  best  treated  by  the  roentgen 
ray  with  the  hope  of  retarding  the  progress  rather  than 
of  curing  the  disease. 

2.    ENDOTHELIOMA 

A  rare  tumor,  similar  in  structure  to  carcinoma,  but 
arising  from  certain  tissues  of  endothelial  origin  like 
the  meninges,  lymph  nodes  or  serous  membranes,  01 
blood  vascular  system.  Some  endotheliomas  (men- 
ingeal tumors)  are  relatively  benign,  while  others  show 
invasive  and  metastatic  tendencies  of  a  definitely  malig- 
nant character. 

Symptoms. — There  are  no  characteristic  symptoms 
of  endotheliomas.  A  tumor  arising  primarily  in  a 
structure  of  endothelial  origin,  usually  of  slow 
growth,  and  of  a  low  degree  of  malignancy  is  occasion- 
ally demonstrated  by  microscopic  examination  to  be  an 


48 

endothelioma.  The  endotheliomas  of  the  meninges 
form  the  most  important  group  of  these  tumors 
because  they  are  one  of  the  relatively  small  number  of 
types  of  brain  tumor  susceptible  to  radical  removal. 
The  symptoms  of  a  meningeal  endothelioma  are  those 
characteristic  of  a  brain  tumor,  and  the  pathologic 
diagnosis  after  removal  is  the  only  positive  evidence 
of  the  nature  of  the  disease. 

Treatment. — The  treatment  of  all  endotheliomas  is 
by  radical  operation,  when  the  situation  is  one  which 
permits  this  measure  to  be  undertaken.  The  prog- 
nosis after  complete  removal  is  very  favorable. 

3.    GLIOMA 

Glioma  is  the  specific  cellular  tumor  of  the  central 
nervous  system,  arising  at  all  ages  and  at  any  point  in 
brain  or  cord,  and  forming  more  than  one  half  of  all 
brain  tumors.  It  is,  however,  a  rare  form  of  malignant 
disease. 

Symptoms. — A  glioma  usually  replaces  a  considerable 
portion  of  brain  tissue,  causing  symptoms  from  (a) 
general  cerebral  pressure,  and  (b)  from  focal  destruc- 
tion of  nerve  tracts  and  centers.  General  pressure 
symptoms  are  severe  headache,  vomiting,  slow  pulse, 
and  choked  disk,  with  amblyopia  or  amaurosis.  Focal 
symptoms  depend  on  the  location  of  the  tumor,  which 
can  often  be  determined  accurately  by  expert  analysis. 
The  course  is  usually  progressive  and  fatal  within  an 
average  of  ten  months.  Gliomas  do  not  produce  bulky 
tumors,  but  replace  a  portion  of  the  brain  by  soft 
vascular  tumor  tissue  or  a  more  solid  opaque  tumor 
mass  which  is  poorly  defined.  A  peculiar  feature  is 
the  tendency  to  sudden  hemorrhage  into  the  tumor 
tissue,  which  may  cause  attacks  suggestive  of  apoplexy. 
The  gliomas  are  prone  to  recur  locally,  but  they  do 
not  produce  metastases.  The  structure  presents  vari- 
able proportions  of  ganglion  cells  and  nerve  fibers, 
most  of  the  cells  being  small  and  round. 

Treatment.  —  The  surgical  treatment  of  glioma, 
involving  craniotomy,  is  very  unsatisfactory,  but  most 
cases  deserve  an  exploratory  operation  on  the  suppo- 
sition that  the  growth  may  be  localized  or  that  some 
less  malignant  tumor  may  be  found.     The  prognosis 


49 

is  grave  on  account  of  the  invasive  character  of  the 
tumor,  and  the  difficulty  of  complete  removal.  In  any 
case  a  decompression  can  be  performed  as  a  palliative 
measure. 

4.    HYPERNEPHROMA 

Although  hypernephroma  is  the  commonest  tumor 
of  the  kidney,  it  is  nevertheless  a  rare  disease.  Most 
hypernephromas  arise  from  the  renal  tissue,  a  few 
from  misplaced  adrenal  rests  in  the  kidney  or  other 
organs,  and  some  from  the  adrenal  itself.  They 
exhibit  all  grades  of  malignancy,  some  being  benign 
adenomas,  some  adenocarcinomas,  and  others  highly 
malignant  carcinomas.  The  cells  are  large  and  clear, 
and  resemble  endothelium.  The  malignant  tumors  are 
extremely  vascular,  grow  rapidly,  and  produce  bulky 
tumors  in  a  few  months.  They  often  invade  the  renal 
vein  and  vena  cava,  and  produce  local  peritoneal  exten- 
sions and  general  metastases  in  liver,  lungs,  bones  and 
brain.  Bulky  destructive  bone  metastases  are  charac- 
teristic, and  often  appear  before  the  primary  tumor 
is  suspected. 

Symptoms. — Local  pain,  a  tumor  in  the  region  of 
the  kidney,  and  hematuria  are  the  chief  diagnostic 
signs.  Roentgen-ray  examinations  of  the  long  bone? 
are  necessary  to  exclude  metastases. 

Treatment. — The  treatment  is  immediate  extirpation 
of  tumor  and  kidney,  but  it  is  successful  only  in  the 
early  stages  of  comparatively  benign  tumors.  The 
first  step  in  the  radical  operation  should  be  the  ligature 
of  the  renal  veins  to  prevent  dislodging  tumor  emboli 
into  the  general  circulation. 

S.    NEUROCYTOMA 

Neurocytoma  is  a  cellular  tumor  derived  from  nerve 
cells.  It  may  originate  from  embryonic  or  adult  nerve 
cells.  Two  groups  of  these  rare  tumors  are  recognized 
— those  arising  in  the  central  nervous  system  (neuro- 
epithelioma) and  those  outside  the  central  nervous  sys- 
tem in  the  distribution  of  the  sympathetic  nervous 
system  (sympathetic  neurocytoma).  Both  tumors  are 
chiefly  of  pathologic  interest  on  account  of  the  identi- 
fication of  typical  neuroblastic  formations  of  cells  in 
rosettes  or  with  the  characteristic  neurofibrils  of  the 


50 

peripheral  nerve  system.  They  are  both  extremely 
malignant.  Their  symptoms  are  not  characteristic,  and 
operative  treatment  rarely  succeeds  in  accomplishing 
their  complete  removal. 

6.    ADAMANTINOMA 

Adamantinoma  is  a  rare  tumor  in  human  beings,  but 
one  of  sufficient  importance  to  justify  its  mention.  It 
usually  occurs  in  young  adults.  The  tumor  arises  from 
the  enamel  organ  of  a  misplaced  or  unerupted  tooth. 
The  structure  of  the  enamel  organ  which  is  designed 
to  secrete  enamel  from  epithelial  cells  surrounding  the 
crown  of  the  unerupted  tooth,  gives  rise  to  a  charac- 
teristic histologic  picture.  When  an  overgrowth  of 
these  cells  takes  place  it  duplicates  a  typical  carcinoma 
— that  is,  solid  columns  of  epithelial  cells  grow  in  a 
fibrous  tissue  matrix.  Although  the  histologic  picture 
is  that  of  carcinoma,  these  growths  are  relatively  less 
malignant.  They  are  locally  invasive  of  the  surround- 
ing tissues,  and  on  this  account  show  a  tendency  to 
recurrence  after  incomplete  removal,  but  only  in  rare 
instances  do  they  produce  remote  metastases. 

Symptoms. — The  symptoms  are  those  of  any  slow 
growing  tumor  of  the  jaw.  The  diagnosis  is  estab- 
lished only  by  a  pathologic  examination  of  the  tissue. 

Treatment. — The  treatment  consists  in  the  thorough 
operative  removal  of  the  disease.  Unless  this  is  accom- 
plished the  danger  of  recurrence  is  considerable. 

7.    CHORIOMA 

Chorioma  or  chorionic  epithelioma  is  a  highly 
malignant  tumor  of  the  uterus  which  occurs  chiefly 
after  hydatid  mole  (44  per  cent.)  ;  after  abor- 
tion (30  per  cent.)  and  after  normal  labor  (22  per 
cent.).  It  occurs  so  frequently  at  a  period  of  from 
five  to  eight  weeks  after  hydatid  mole  that  all  such 
cases  should  be  watched  for  the  development  of. 
malignant  disease.  All  moles  should  be  carefully 
examined  in  the  gross  and  microscopically  for  malig- 
nant changes.  Adherent  moles  or  placentas  and  mul- 
tiple pregnancies,  especially,  predispose  to  chorioma. 

Symptoms. — The  chief  symptom  is  repeated  bleed- 
ing from  the  uterus,  which  may  or  may  not  be 
enlarged.     The  bleeding  usually  begins  in  the  third 


51 

month  of  a  supposed  pregnancy.  Bluish  vaginal  metas- 
tases have  often  been  the  first  sign  detected.  The 
diagnosis  is  to  be  made  from  the  curettings,  showing 
the  characteristic  two  types  of  cells  of  syncytial  and 
Langhans  layers.  The  prognosis  is  always  unfavor- 
able, but  when  villi  are  preserved  in  the  tumor 
(destructive  placental  polyp)  not  a  few  cases  have 
recovered.  The  association  of  chorioma  with  large 
corpus  luteum  cysts  is  thought  to  be  of  significance  in 
the  origin  of  these  tumors,  and  it  is  believed  by  certain 
writers  that  it  is  in  response  to  the  excessive  internal 
secretion  of  these  lutein  cysts  that  the  syncytial  cells 
take  on  the  enhanced  invasive  growth  which  leads  them 
to  perforate  into  the  blood  vessels  and  produce  remote 
metastases. 

Treatment. — The  treatment  is  hysterectomy. 

8.     TERATOMAS     AND      MIXED     TUMORS 

Among  the  rare  types  of  malignant  disease  are  the 
two  groups  of  tumors  of  embryonic  origin,  called 
teratomas  and  mixed  tumors.  Not  all  tumors  of  these 
two  groups  are  malignant,  although  all  may  be  said  to 
have  potential  malignancy.  They  are  due  to  vestiges 
of  tissue  misplaced  in  embryonic  life. 

Tumors  of  the  teratoma  class  may  be  regarded  as 
misplaced  and  incompletely  developed  masses  of  tissue, 
which  if  not  misplaced  and  incompletely  developed 
would  have  formed  a  complete  fetus — a  twin  to  the 
individual  who  presents  the  tumor. 

Mixed  tumors  are  due  to  misplaced  vestiges  of  tissue 
less  complicated  than  the  teratoma,  yet  including  two 
or  more  distinct  tissues  arising  from  different  ger- 
minal layers.  The  best  examples  of  teratomas  are  pro- 
vided by  the  mixed  tumors  of  the  testicle  and  ovary, 
which  present  tissues  of  great  variety  from  all  three 
germinal  layers,  skin,  gland-tissue,  bone,  cartilage, 
endothelium,  and  a  variety  of  mesoblastic  tissues.  The 
more  common  mixed  tumors  are  those  occurring  in 
the  salivary  glands,  and  show  chiefly  glandular  epithe- 
lium and  cartilage,  and  various  types  of  more  or  less 
embryonic  connective  tissue. 

Certain  of  these  teratomas  and  mixed  tumors  remain 
virtually  benign  tumors  throughout  life,  while  others 
undergo  malignant  change  and  develop  a  tendency  to 
rapid  infiltrative  growth  and  metastases  of  the  most 


52 

malignant  character.  While  the  form  of  malignant 
change  which  is  most  common  in  these  tumors  is  that 
productive  of  tissue  of  a  carcinomatous  type,  some 
tumors,  especially  those  of  the  testicle,  show  areas 
which  are  not  distinguishable  from  sarcoma,  and  the 
terms  of  carcinoma  and  sarcoma  have  been  used  some- 
what loosely  in  describing  tumors  of  this  type  in  litera- 
ture. 

Symptoms. — No  symptoms  are  especially  character- 
istic of  the  teratomas  and  mixed  tumors.  Their  origin, 
however,  being  largely  restricted  to  certain  special 
regions,  leads  to  the  suspicion  of  the  diagnosis  when 
tumors  of  previously  slow  growth  in  those  regions 
suddenly  take  on  malignant  characteristics. 

The  teratomas  occur  chiefly  in  the  ovary,  testicle, 
base  of  the  skull,  and  in  the  mediastinum,  whereas  the 
mixed  tumors  are  found  chiefly  in  the  region  of  the 
salivary  glands,  the  breast  and  the  kidney. 

The  diagnosis  .of  tumors  of  this  character  depends 
ultimately  upon  the  pathologic  examination  of  the 
tissue,  and  the  recognition  of  its  complicated  structure. 

The  treatment  in  the  earliest  stages — i.  e.,  before 
the  tumor  shows  extensive  metastases,  consists,  of 
course,  of  radical  surgical  removal.  After  the  stage 
of  possible  cure  by  operation  has  passed,  roentgen  rays 
and  radium  offer  the  only  hope  of  delaying  the  progress 
of  the  disease,  and  of  relieving  the  patient's  symptoms 
as  they  arise. 


VII 

TREATMENT  OF  INOPERABLE 

OR   RECURRENT    CANCER 


Much  may  be  done  to  relieve  the  patient  with  recur- 
rent cancer.  Not  only  can  life  be  prolonged,  but  it  can 
be  made  much  more  comfortable  by  palliative  treat- 
ment. The  more  important  methods  of  treatment  are 
as  follows : 

1.  Roentgen  Ray. — Heavy  treatments  with  roentgen 
rays  from  a  tube  of  standard  strength  up  to,  but  not 
beyond,  the  resisting  power  of  the  adjoining  skin,  can 
be  used  to  relieve  pain,  diminish  sloughing  and  dis- 
charge, and  to  retard  growth  or  even  cause  shrinkage 
of  tumor  tissue.  Where  the  tumor  tissue  is  superficial 
and  ulcerated  the  best  effects  are  obtained,  and  when 
the  tumor  tissue  is  spread  over  a  wide  area,  as  in 
recurrent  cancer  of  the  breast,  roentgen  rays  are  to 
be  preferred  to  radium.  For  deeply  situated  tumors 
(abdominal,  mediastinal,  etc.)  the  roentgen  ray  is  of 
value,  although  its  results  are  not  so  certain. 

2.  Radium. — Radium  can  be  used  in  much  the  same 
manner  as  roentgen  rays.  It  is  not  so  well  adapted  to 
the  treatment  of  large  superficial  areas  as  the  roentgen 
ray,  but  for  intensive  treatment  of  smaller  superficial 
areas,  and  for  deep  tumors  of  the  mediastinum  and 
prostate,  its  effects  are  promising.  It  is  especially  val- 
uable in  recurrent  cancer  of  the  cervix  and  of  the 
body  of  the  uterus,  in  cancer  of  the  rectum  and  pros- 
tate, in  superficial  and  inoperable  cancer  of  the  mouth 
and  pharynx,  and  in  some  of  the  more  general  dis- 
eases, such  as  leukemia  and  lymphoma,  or  Hodgkin's 
disease. 

3.  Palliative  Operations. — Palliative  operations  are 
often  indicated  in  cases  of  recurrent  cancer  to  relieve 
the  patent  of  an  offensive  sloughing  tumor,  or  merely 
for  the  relief  of  pain  or  of  other  mechanical  symptoms. 
In  such  cases  the  cautery  can  often  be  employed  to 
advantage  for  the  control  of  hemorrhage,  and  to 
increase  the  destruction  of  tumor  tissue  without  dis- 
semination. Operations  of  this  nature  are  often  advis- 
able in  recurrent  cancer  of  the  cervix  and  of  the  breast. 


54 

In  cancer  of  the  pharynx  or  larynx  tracheotomy  is 
often  an  operation  of  necessity,  and  in  incurable  cases 
of  cancer  of  the  stomach  or  intestine,  where  obstruc- 
tion exists,  a  palliative  gastro-enterostomy  or  an  intes- 
tinal anastomosis  may  relieve  the  patient's  most  dis- 
tressing symptoms.  Colostomy  gives  relief  to  much 
of  the  distress  in  cancer  of  the  rectum,  and  a  supra- 
pubic drainage  gives  relative  comfort  in  cases  of 
advanced  cancer  of  the  bladder  and  prostate.  In  many 
cases  of  advanced  cancer  about  the  face,  a  combination 
of  operation,  cautery,  and  radium  or  roentgen-ray 
treatment  may  yield  results  quite  unattainable  by  any 
one  method  used  alone.  Finally,  even  so  severe  an 
operation  as  an  amputation  at  the  shoulder  joint  may 
be  performed  for  the  "brawny  arm"  of  recurrent  can- 
cer of  the  breast  to  relieve  the  patient  of  an  intolerable 
burden. 

4.  Symptomatic  Treatment. — Symptomatic  treatment 
of  recurrent  cases  of  cancer  yields  results  in  the  way 
of  relief  of  suffering  which  have  not  always  been 
appreciated.  Opiates  are  indicated  as  surely  in  hope- 
less cases  of  cancer  as  in  any  other  condition  with 
which  the  physician  has  to  deal.  Their  use,  however, 
should  be  guarded,  and  should  be  supplemented  with 
other  sedatives  in  order  to  delay  the  necessary  increase 
of  dosage. 

Where  the  pain  of  nerve  pressure  exists,  as  in  spinal 
metastases  or  tumor  infiltration  of  the  brachial  or 
lumbar  plexus,  special  operations  for  the  division  of 
sensory  nerves  or  spinal  nerve  tracts  may  be  advisable, 
although  such  measures  are  not  widely  practised. 

Finally,  the  nurse  can  contribute  quite  as  much  to 
the  comfort  of  the  advanced  case  of  recurrent  cancer 
as  can  the  physician.  Frequent  and  gentle  dressing  of 
ulcerated  surfaces  to  diminish  discharges,  relieve  offen- 
sive odors  and  prevent  distressing  infections,  do  much 
to  make  the  patient's  condition  bearable,  while  the 
maintenance  of  a  comfortable  position,  the  avoidance 
of  pressure  sores,  the  occupation  of  the  mind  of  the 
patient,  and  the  maintenance  of  nutrition  by  carefully 
selected  nourishment,  all  help  materially  to  alleviate 
distress. 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE   BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

MG. 

9  ' 

a 

■■;     ..      - 

M 

IQl  81943 

C2BI1  140IM1OO 

"*! 


RC261  Am323 

American  society  for  the  control 


! 


I  I 


